Splint-Assisted Reduction of Comminuted or Complex Maxillofacial Fractures:

Surgical Guide Splint Fabrication via Virtual Surgical Planning for Complex Mandible Fractures in the Trauma Setting

INTRODUCTION

In cases of significantly displaced or comminuted mandible fractures, surgical guide splints can be developed to create the normal preinjury occlusion rather than placing patients in maxillomandibular fixation. Standard fracture fixation involves bending of plates intraoperatively based on surgeon-constructed dental splints which is prone to error.

METHODS

A 38-year-old male experienced a gunshot wound to the face that resulted in mandibular angle fractures bilaterally causing severely deranged occlusion and free-floating anterior mandible segment. Virtual surgical planning (VSP) software was used to recreate the injury-induced anatomy and anticipated postoperative anatomy. It also provided a surgical guide splint and a framework to preoperatively bend reconstruction plates to assist in achieving proper occlusion.

RESULTS

He underwent open reduction internal fixation of comminuted mandible fractures with lingual guide splint placement 10 days after injury. Following lingual splint application, the reconstruction plate was applied from angle to angle. The lingual splint was maintained for 3 weeks postoperatively to support the stabilization, and he was able to tolerate a regular diet and showed no evidence of wound breakdown.

DISCUSSION

Virtual surgical planning has had important implications in craniofacial surgery, orthognathic surgery, maxillomandibular reconstruction, and orbital reconstruction after tumor resection, temporomandibular joint surgery, and others. However, there have only been isolated reports describing the role of VSP in the facial trauma setting. In this technical study, the authors demonstrate the benefits of VSP and surgical guide splinting in trauma settings.

Orthodontic Approaches in the Management of Mandibular Fractures: A Scoping Review

Non-surgical approaches have been proposed in the management of mandibular fractures, especially in children, but there is a lack of clear guidelines on the clinical indications of conservative approaches. The aim of this scoping review is to provide the available evidence of the role of the orthodontist in the management of mandibular fractures. The PRISMA-ScR guidelines were followed to select eligible articles from the PubMed, Scopus, and Web of Science databases according to precise inclusion criteria. The research questions were formulated as follows: "what is the scientific evidence concerning the rule of orthodontists in the management of mandibular fractures" and "the preferential use of the direct bonding technique with orthodontic brackets rather than rigid arch bars"? Seventeen articles were included. Five articles presented the use of removable acrylic splints or functional appliances, six articles concerned the employment of cemented acrylic or rigid splints, and six articles described the management of mandibular fractures in adults and children using orthodontic brackets or mini-screws. Most of these techniques have been employed in children and growing subjects, while fewer data were available regarding conservative treatments in adults. Preliminary evidence suggests that condylar and some minor parasymphyseal fractures in children may be managed with conservative approaches. In adults, minor condylar and stable body mandibular fractures with minimal displacement have been reduced similarly. However, there are no sufficient elements that could suggest the preferential use of orthodontic brackets over rigid arch bars in adults. Further randomized and non-randomized clinical trials with long follow-ups will be needed to better define the clinical indications of the orthodontic approaches in the management of mandibular fractures based on severity, location, and age.

Contemporary management of complex craniofacial trauma: virtual planning, navigation and the novel thermoformed cage splints in a strategic, sequential, computer-guided protocol

INTRODUCTION

It was the aim of the study to assess if computerized simulation and the use of thermoformed cage splints are useful to plan cases of complex craniofacial trauma.

MATERIALS AND METHODS

patients with fractures in any of the thirds of the craniofacial skeleton and occlusion impairment. Virtual surgical planning with digital reduction of fractures, navigated planning, thermoformed cage splints were used in all cases. Surgical outcomes were evaluated by computing the surface deviation and occlusograms between planned and postoperative models.

RESULTS

13 patients were enrolled in this study. Accuracy of bone repositioning was evaluated compared with the surgical planning. For the mandible, mean Root Mean Square Error (RMSE) was of 1.67 with a standard deviation (SD) of ±0.75 mm (p < 0.001); for the maxilla, average RMSE was of 0.88 with SD of ±0.52 mm (p < 0.001); and for midfacial and upper third bone segments, average RMSE was of 0.59 with SD of ±0.47 mm (p < 0.001) CONCLUSIONS: Within the limitations of the study it seems that thermoformed cage splints might be a promising alternative to other well-established approaches for accurate occlusal restoration and can be fully integrated within the digital workflow.

Repairing Facial Fractures with Interrupted Maxillary-mandibular Arches by Computer-assisted Reverse Planning Model Surgery

Background:

Management of comminuted facial fractures with maxillary-mandibular arch interruption is difficult, resulting in inadequate bone reduction and malocclusion. Traditionally, a good quality dental splint is helpful, but difficult to obtain in acute trauma. We apply a computer-assisted design and three-dimensional printing technology to improve splint fabrication and utilization, thus facilitating restoration of dental occlusion and facial fracture.

Methods:

We retrospectively reviewed patients who suffered from facial fractures with interruption of the maxillary-mandibular arches. We developed the “computer-assisted reverse planning and three-dimensional printing model surgery” algorithm and applied it in selected patients. An occlusal splint was created as a surgical guide to enhance the maxilla-mandibular unit repair by taking care of the bone reduction and occlusion. All included patients were followed up to assess the functional outcome and patients suitable for this method.

Results:

From Jan 2015 to Aug 2020, 10 patients (eight men and two women) with comminuted facial fractures were included. The average time of surgery was 9.2 days. The average follow-up time was 8.6 months. There was no patient who needed major revision to correct malocclusion or facial asymmetry.

Conclusions:

A computer-assisted design splint decreases intraoperative inaccuracies and difficulty in comminuted maxillo-mandibular fractures. It is a useful and reliable alternative. Collaboration with an experienced engineer and patient selection are indispensable in delivering successful outcomes. Patients who have more than three bone fragments in a single dental arch or more than four bone fragments in the entire maxillary-mandibular unit appear to be excellent candidates for this method.

Treatment of Gunshot-Related Mandibular Fracture with Splint-Guided Reduction: Case Report

Background/Aim: Gunshot injury-related mandibular fractures often have a complex pattern, characterized by comminution, bone loss, and soft-tissue avulsion. The management is difficult and varies between individual cases.

Case Report: A 41-year-old male patient presented with marked swelling and ecchymosis in the left mandibular region. Intraorally, he had a deviated open bite on the left side. A unilateral comminuted mandibular fracture was diagnosed by panoramic radiograph and computed tomography. An acrylic dental splint-guided open reduction and internal fixation, including intermaxillary fixation through brackets and intermaxillary elastics, was planned. No complications were observed throughout the healing period, and healing at the fracture site was satisfactory. The occlusion returned to the preinjury position and was stable.

Conclusions: This case report shows that successful functional and esthetic results can be achieved with a strict patient-specific treatment protocol for a comminuted mandibular fracture due to gunshot injury.

Many Moving Pieces: Virtual Preoperative Surgical Planning for Traumatic Occlusal Splints

INTRO

Achieving anatomic reduction and re-establishing premorbid occlusion in patients with complex maxillomandibular fractures is challenging even for seasoned surgeons. Historically, surgeons have utilized occlusal splints to help establish occlusal relationships before fracture reduction and fixation. These acrylic splints are fabricated from dental impressions and require manual repositioning of tooth bearing segments along the fracture line to reapproximate premorbid occlusion. The process is laborious, requires a dental lab, and is less efficacious in edentulous patients or those with significantly comminuted fractures; as such it has largely fallen out of practice. Recently, with advances in virtual 3D modeling and printing, we demonstrate that occlusal splints can be designed from computed tomography scans, manipulated virtually, and printed without obtaining impressions from the patient.

METHODS/RESULTS

In our series of 3 patients with complex maxillomandibular fractures, occlusal splints were created by 1) obtaining maxillofacial computed tomography scans, 2) reducing the fractures virtually, and 3) using orthognathic virtual surgery software to create the splint. The time between planning and delivery of the splint was 4 to 7 days. These splints were successfully utilized to help establish premorbid occlusion in conjunction with maxillomandibular fixation and aided in expeditious intraoperative fracture reduction and fixation.

CONCLUSIONS

In the treatment of complex facial fractures, occlusal splints can be a useful adjunct in the operative reduction and fixation of fractures. With the advent of virtual preoperative surgical planning via 3D modeling and 3D printing, these occlusal splints can be created of a sufficient fidelity to avoid the strict need for dental impressions.

Versatility of Hard Occlusal Splints in Optimizing Outcomes in Patients with Old Pan-facial Fractures

Pan-facial fracture repair is considered one of the most challenging complex reconstructive procedures to perform. It is always better to treat facial fractures as soon as possible. A delay of several days or weeks makes an ideal anatomic reduction difficult, if not impossible.

Dentoalveolar Fractures: New Orthodontic Protocol Proposal and Pilot Study

The goal of fracture treatment that includes the dentoalveolar process is to obtain the anatomic bone healing and the pre-injury occlusion restoration with functional and aesthetic recovery, avoiding dental or periodontal lesions. Fractures activates, in the damaged tissue, the Regional Acceleratory Phenomenon, a physiological healing process that can also be activated during orthodontic overloads. Orthodontic treatment in the traumatized area could exploit this phenomenon in order to sustain the cellular activity.The aim of this study is to propose a treatment protocol for dentoalveolar fractures based on the use of orthodontics in order to sustain the physiological healing process known as Regional Acceleratory Phenomenon.The authors present 2 cases of an 18 year old woman and 23 year old man affected by dentoalveolar fracture. The operative protocol the authors applied foresaw three steps of treatment: orthodontic brackets application, surgery, orthodontic treatment.The patients showed complete healing at the 3 months follow-up and were treated up to 18 months for further orthodontic treatment.The operative protocol proposed by the Authors appears to be a rational choice since it allows a single orthodontic device to be an "active splinting system", with fast application time, good acceptance by the patient, low complications rate; moreover, it produces any planned dental movements for further orthodontic treatments.

Utilization of Virtual Surgical Planning for Surgical Splint-Assisted Comminuted Maxillomandibular Fracture Reduction and/or Fixation

Study Design

This article was a technical note.

Objective

To demonstrate the utilization of virtual surgical planning for surgical splint (VSPSS) fabrication. The VSPSS was used as an intraoperative assisting and guiding tool for reduction and/or fixation of treatment of comminuted maxillomandibular fractures.

Methods

The presented technical note showed the fabrication process that began with data acquisition and presurgical planning using virtual surgical planning (VSP). The VSPSS was designed and fabricated after the fractures were reduced digitally in VSP. In the operating room, the VSPSS was seated to guide reduction and/or allow satisfactory fixation in three different situations.

Results

Postoperative radiographs showed an acceptable reduction of the fractures. All patients had stable and repeatable occlusion postoperatively.

Conclusions

The VSPSS is a feasible tool for surgeons to assist in the comminuted maxillomandibular fracture management, decrease operating time, and improve fracture stability.

The mandibular symphysis as a starting point for the occlusal-level reconstruction of panfacial fractures with bicondylar fractures and interruption of the maxillary and mandibular arches: report of two cases

Panfacial fractures represent a challenge, even for experienced maxillofacial surgeons, because all references for reconstructing the facial skeleton are missing. Logical reconstructive sequencing based on a clear understanding of the correlation between projection and the widths and lengths of facial subunits should enable the surgeon to achieve correct realignment of the bony framework of the face and to prevent late deformity and functional impairment. Reconstruction is particularly challenging in patients presenting with concomitant fractures at the Le Fort I level and affecting the palate, condyles, and mandibular symphysis. In cases without bony loss and sufficient dentition, we believe that accurate fixation of the mandibular symphysis can represent the starting point of a reconstructive sequence that allows successful reconstruction at the Le Fort I level. Two patients were treated in our department by reconstruction starting in the occlusal area through repair of the mandibular symphysis. Both patients considered the postoperative facial shape and profile to be satisfactory and comparable to the pre-injury situation.