Traumatic brain injuries and maxillofacial fractures: a systematic review and meta-analysis

Traumatic brain injuries (TBIs) associated with maxillofacial fractures (MFFs) are a public health concern worldwide, especially among adult-aged males. There is an urgent need for early detection of associated TBIs in patients with MFFs during the initial assessment and treatment stage to reduce morbidity and mortality. The objective of the present study was to systematically review the literature to determine specific MFF situations associated with TBIs and to identify the factors associated with TBIs in patients with MFFs. The protocol was developed in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and was registered to the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42020155912. Overall, of 26,774 patients recorded, 13,667 patients (51.04%) sustained MFFs with an associated TBI. The male to female ratio was 4.8:1. RTA was the most common cause. The most common TBIs were concussions, contusions, and closed brain injuries. Within the limits of this study, it was concluded that TBI-related MFFs should be suspected whenever maxillary or mandibular bone fractures occur, especially among adults, males, and people with injuries caused by RTAs and assaults. There is a need to increase the awareness of maxillofacial surgeons on the possible associations of combined maxillofacial trauma and brain injuries.

A clinical decision aid for patients with suspected midfacial and mandibular fractures (the REDUCTION-I study): a prospective multicentre cohort study

Purpose

To assess physical examination findings related to maxillofacial trauma to identify patients at risk of midfacial and mandibular fractures and then to construct a clinical decision aid to rule out the presence of midfacial and mandibular fractures in emergency department patients.

Methods

We performed a prospective multicentre cohort study in four hospitals in the Netherlands, including consecutive patients with maxillofacial trauma. Each patient received a standardized physical examination consisting of 15 and 14 findings for midfacial and mandibular traumas, respectively. Consequently, clinical decision aids were constructed with the focus being on ruling out the presence of midfacial and mandibular fractures, and diagnostic accuracy was calculated.

Results

A total of 993 consecutive patients were identified of whom 766 and 280 patients were suspected of midfacial and mandibular fractures, respectively. Midfacial fractures were diagnosed in 339 patients (44.3%), whereas mandibular fractures were observed in 66 patients (23.6%). The decision aid for midfacial trauma consisting of peri-orbital hematoma, epistaxis, ocular movement limitation, infra-orbital nerve paresthesia, palpable step-off and tooth mobility or avulsion, produced a sensitivity of 89.7 (86.0–92.5), a specificity of 42.6 (38.0–47.4), and a negative predictive value of 83.9% (78.4–88.2). The decision aid for mandibular trauma consisting of the angular compression test, axial chin pressure test, objective malocclusion, tooth mobility or avulsion and the tongue blade bite test resulted in a sensitivity of 98.5 (91.9–99.7), a specificity of 34.6 (28.5–41.2), and a negative predictive value of 98.7% (92.8–99.8).

Conclusion

The constructed clinical decision aids for maxillofacial trauma may aid in stratifying patients suspected for midfacial and mandibular fractures to reduce unnecessary diagnostic imaging.

Clinical Trial Registration

The study was registered at ClinicalTrials.gov with the identifier NCT03314480.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01968-1.

Real-time screening tool for identifying post-traumatic stress disorder in facial trauma patients in a UK maxillofacial trauma clinic

Post-traumatic stress disorder (PTSD) is a distressing consequence of a traumatic event associated with an increased suicide risk and reduced quality of life. Surgeons often have low confidence in identifying psychological problems. The prevalence of PTSD following facial trauma ranges from 23% to 41%. This highlights the importance of identifying and managing at-risk patients to optimize both mental and physical recovery. IMPARTS (Integrating Mental and Physical healthcare: Research, Training and Services) provides electronic screening tools to guide the non-mental health clinician in the 'real-time' identification, documentation, and management of potential mental health problems. The bespoke IMPARTS facial trauma screening tool was piloted in a UK oral and maxillofacial surgery trauma clinic from July 2015 to November 2017. A total of 199 patients completed screening, with 48 (24%) screening positive for possible PTSD. Further analysis of these 48 patients revealed that four (8%) had PTSD symptoms alone; three (6%) also screened positive for depression, 17 (35%) for co-existing symptoms of anxiety, and 24 (50%) for PTSD, anxiety, and depression. IMPARTS was found to be a highly effective tool aiding the non-mental health clinician to screen for PTSD and initiate prompt management. The data captured informs planning of the psychological support service.

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.

Maxillofacial trauma: managing potentially dangerous and disfiguring complex injuries [digest]

Patients with maxillofacial trauma require a careful evaluation due to the anatomical proximity of the maxillofacial region to the head and neck. Facial injuries can range from soft-tissue lacerations and nondisplaced nasal fractures to severe, complex fractures, eye injuries, and possible brain injury. Though the Advanced Trauma Life Support (ATLS) guidelines provide a framework for the management of trauma patients, they do not provide a detailed reference for many subtle or complex facial injuries. This issue adds a more comprehensive and systematic approach to the secondary survey of the maxillofacial area and emergency department management of injuries to the face. In addition to an overall review of maxillofacial trauma pathophysiology, associated injuries, and physical examination, this review will also discuss relevant imaging, treatment, and disposition plans. [Points & Pearls is a digest of Emergency Medicine Practice].

Maxillofacial Trauma: Managing Potentially Dangerous And Disfiguring Complex Injuries

Patients with maxillofacial trauma require a careful evaluation due to the anatomical proximity of the maxillofacial region to the head and neck. Facial injuries can range from soft-tissue lacerations and nondisplaced nasal fractures to severe, complex fractures, eye injuries, and possible brain injury. Though the Advanced Trauma Life Support (ATLS) guidelines provide a framework for the management of trauma patients, they do not provide a detailed reference for many subtle or complex facial injuries. This issue adds a more comprehensive and systematic approach to the secondary survey of the maxillofacial area and emergency department management of injuries to the face. In addition to an overall review of maxillofacial trauma pathophysiology, associated injuries, and physical examination, this review will also discuss relevant imaging, treatment, and disposition plans.

Incidence and patterns of maxillofacial trauma-a retrospective analysis of 3611 patients-an update

BACKGROUND

Maxillofacial fractures occur in a significant proportion worldwide and can occur as an isolated injury or in combination with other severe injuries including cranial, spinal, and upper and lower body injuries requiring prompt diagnosis with possible emergency interventions. The epidemiology of facial fractures varies with regard to injury type, severity, and cause and depends on the population studied. Hence, understanding of these factors can aid in establishing clinical and research priorities for effective treatment and prevention of these injuries.

MATERIALS AND METHODS

In this present retrospective study, we provide a comprehensive overview regarding cranio-maxillofacial trauma on 3611 patients to assist the clinician in assessment and management of this unique highly specialized area of traumatology. A preformed pro forma was used to analyze the medical records of patients treated for facial trauma in The Department of Oral and Maxillofacial Surgery, Meenakshi Ammal Dental College and Hospital, Chennai. The distribution according to age, gender, etiology, type of injury, time interval between accident and treatment, loss of consciousness, facial bones involved, pattern of fracture lines, treatment offered, and postoperative complications were recorded and evaluated.

RESULTS

We inferred male patients sustained more injuries mostly in the third decade of age. Road traffic accidents were the most common cause of injury. Mandible was the most commonly fractured bone in the facial skeleton. Soft tissue injuries occurred more in road traffic accidents and upper lip was the commonest site of injury.

CONCLUSION

Our study provides insights into the epidemiology of facial injuries and associated factors and can be useful not only in developing prevention strategies but also for grading the existing legal regulations and also for framing a more effective treatment protocol.

Maxillofacial trauma scoring systems

The changing complexity of maxillofacial fractures in recent years has created a situation where classical systems of classification of maxillofacial injuries fall short of defining trauma particularly that observed with high-velocity collisions where more than one region of the maxillofacial skeleton is affected. Trauma scoring systems designed specifically for the maxillofacial region are aimed to provide a more accurate assessment of the injury, its prognosis, the possible treatment outcomes, economics, length of hospital stay, and triage. The evolution and logic of such systems along with their merits and demerits are discussed. The author also proposes a new system to aid users in quickly and methodically choosing the system best suited to their needs without having to study a plethora of literature available in order to isolate their choice.

Maxillofacial gunshot wounds in peacetime

The treatment of maxillofacial gunshot wounds in peacetime is an urgent and difficult problem. The emergence of new types of civilian weapons and relatively small current clinical experience does not allow generating recommendations for the treatment of this pathology. It presents a statistical analysis of injuries in St. Petersburg 2004-2014 restricted firearms destruction and experimental study of the harmful effect of these weapons on the fabric maxillofacial experimental animals (pigs). The features of the clinical picture, diagnosis and surgical treatment of wounds of the maxillofacial region, caused by a firearm -restricted lesions and wounds with extensive tissue damage maxillofacial caused a hunting weapon are considered.

Interrelationship of Structure and Function in Maxillofacial Fractures

Surgical fixation of maxillofacial fractures can be associated with a myriad of surgical complications. Specific complications correlate with the type of fracture. The authors present a case of multiple maxillofacial fractures, briefly review various types of fractures, and discuss the operative decision-making process. This case report serves as an important reminder that the operative decision-making process should take into account a patient's entire clinical condition.

Early orthodontic treatment: a new index to assess the risk of malocclusion in primary dentition

AIM

A new index targeted on the risk of malocclusions in primary dentition, called Baby-ROMA (Risk Of Malocclusion Assessment) index, was set up to assess risks/benefits in early orthodontic therapies. The Baby-ROMA index was designed from the observation that some of the malocclusion signs, observed in primary dentition, can worsen with growth, others remain the same over time and others can even improve. Therefore it would be important to classify the malocclusions observed at an early stage on a risk- based scale.

MATERIALS AND METHODS

The reliability of the index was tested on 200 children, referred by their paediatricians to two different Orthodontic Departments, aged 4-6 years and in full primary dentition. The children were evaluated by two operators, both trained and calibrated on the use of the Baby-ROMA index.

RESULTS

The K test showed a high reproducibility of the index. It is shown that 50% of patients presented malocclusion and crossbite had the highest prevalence, followed by tooth decay and early loss of deciduous teeth and negative overjet.

CONCLUSION

The Baby-ROMA index was helpful to assess the severity of malocclusion and the timing for orthodontic treatment in very young patients (primary teeth).

[Modern technologies in cranio-maxillofacial surgery]

Modern technologies are influencing medicine everyday. The oral and maxillofacial surgery meet the worlds from medicine and dentistry. So technologies from both fields are utilized. This article provides an overview about technologies in clinical use, which are typical for the specialty. Their principles and indications are described as well as benefits and limitations. Based on Cone Beam Computed Tomography image fusion and mirroring techniques are explained as well as patient specific models and implants, template guided and free surgical navigation with and without intraoperative three-dimensional imaging. An overall assessment reveals further need of research regarding indications and patient benefit.

[Peace-time gunshot maxillofacial injury in Arkhangelsk region]

We analyzed civilian gunshot wounds of maxillofacial area in 87 patients living in the Arkhangelsk region. It is noted that gunshot injuries most often occur as a result of the attempted suicide (45 cases (51,7%)), firearm associated crimes (33 cases (37,9%)) and careless handling with the weapon (9 cases (10,4%)). The most common wound canal features are described. In the majority of cases tangential gunshot wounds were seen (55 cases (63,2%)), penetrating wounds (19 cases (21,8%)) and perforating wounds (13 cases (15)). During the last years increased the number of gunshot injures by traumatic weapons (11 (12.6%)). It is recommended to take into consideration the direction and topography of the wound canals during the debridement.

[Structure and specific diagnostic features of neurologic deficiencies in patients with maxillofacial injuries admitted to Stavropol Maxillofacial Surgery Unit]

The purpose of the study was to evaluate the structure of maxillofacial trauma associated with brain injury in Stavropol to elaborate the diagnostic approach. We analyzed 2,604 case records of patients with maxillofacial trauma in the Stavropol region in the period from 2008 to 2012. Only 345 (13.2%) cases were diagnosed with maxillofacial trauma associated with mild brain injury. The analysis of case records showed that the incidence of brain damage depends on the location and type of fracture of the facial bones. It is noted that emotional and stress factors often mask neurological symptoms that are important in the diagnosis of traumatic brain injury. To ensure the treatment success and reduce the duration of disability patients with maxillofacial trauma must be provided with special treatment with a more thorough analysis of possible neurological deficit followed by mandatory therapy for neurological symptoms.

Maxillofacial and concomitant injuries in multiple injured patients at Korle Bu Teaching Hospital, Ghana

BACKGROUND

Patients with maxillofacial injuries may sustain concomitant injuries. The presentation of other injuries may be the initial focus of attention of the primary attending surgeon who may miss the maxillofacial injuries to the detriment of the patient.

OBJECTIVE

To determine the incidence of injuries associated with maxillofacial injuries at Korle Bu Teaching Hospital (KBTH) from January 2009 to December 2010.

METHODS

A prospective study was carried out on patients who were referred to the Maxillofacial Unit of the University of Ghana Dental School and KBTH over the two years with maxillofacial injuries. Their age, sex, type of injury in the maxillofacial region, its aetiology and concomitant injuries were charted. The data was analysed using SPSS 16.0 software.

RESULTS

Two hundred and fifty eight (258) patients were seen of which 67 (26.0%) had concomitant injuries. The average age was 29.1 years. The peak incidence was in the age group 21-30 (N=73, 28.3%). 74% were male and 26.0% female. The commonest cause of injury was road traffic accident (RTA) (N=142;55.0%). 52.7% (N=136) of the patients had injuries of the maxillofacial region. 26.7% (N=69) had mandibular fractures, 19.4% (N=50) had middle third fractures and 8.1% (N=21) had fractures of both. Concomitant injuries were mainly orthopaedic (N=31;12%) and the head and spinal region (N=29;11.2%).

CONCLUSION

A significant number of patients who suffer maxillofacial injuries also sustain injuries of other parts of the body at KBTH. Prompt multidisciplinary management may contribute to improved outcomes.

Combating child abuse: the role of a dentist

BACKGROUND AND PURPOSE

Child abuse has serious physical and psychosocial consequences which adversely affect the health and overall well-being of a child. However, in a developing country like India there has been no knowledge of the extent, magnitude and trends of the problem. This study reviews the overall scenario of child abuse in India as well as the role of the dentist in recognising and thereby combating this problem.

RESULTS

Among health professionals, dentists are probably in the most favourable position to recognise child abuse, with opportunities to observe and assess not only the physical and the psychological condition of the children, but also the family environment. The high frequency of facial injuries associated with physical abuse places the dentist at the forefront of professionals to detect and treat an abused child. Screening for maltreatment should be an integral part of any clinical examination performed on a child. Although many injuries are not caused by abuse, dentists should always be suspicious of traumatic injuries. The dental professional's role in child abuse and neglect is to know the current state law regarding reporting child abuse and to follow the law. Awareness, identification, documentation and notification should be carried out by the dentist.

CONCLUSION

Paediatric dentists can provide valuable information and assistance to physicians about oral and dental aspects of child abuse and neglect. Such efforts will strengthen the ability to prevent and detect child abuse and neglect and enhance care and protection for the children.

Orbito-antro-cervical foreign body impaction: reminder of a CT scan and ultrasonography pitfall

INTRODUCTION

Foreign body impaction within the maxillofacial region is not an uncommon occurrence. Imaging of such objects is of paramount importance to their retrieval in order to assess their relation to vital structures as well as avoid disruption of such structures while retrieving the foreign bodies. We report a case of wooden foreign body which traversed the maxillofacial region, imaging of which posed a significant challenge.

METHODS

A sixteen year old female presented with a wooden foreign body impaction following a road traffic accident. Challenges in the course of investigation and events during the surgical retrieval of the foreign body are described.

RESULT

An unusual case of foreign body impaction transecting the right orbit, right antrum and the pharynx is presented. The inability of both Computed Tomographic scan and Ultra Sound scan to identify the path and relations of the impacted foreign body was also discussed.

CONCLUSION

Computed Tomography and Ultrasonography may not be sufficient to delineate the path and relations of an impacted foreign body especially if the nature of the foreign body is not metallic.

Violence and abuse: core competencies for identification and access to care

Violence and abuse (V/A) is recognized as a significant public health problem, especially in females. Injuries to the head, neck, and/or mouth are clearly visible to the dental team during examination. This article provides compelling evidence that supports the pivotal position occupied by oral health care professionals within the arena of detection, intervention, and prevention of V/A. This article reviews the epidemiology of orofacial risk factors for V/A, diagnostic tools and surveys for identifying victims of all ages, and suggests interdisciplinary educational curricula/specific algorithms to provide the necessary core competencies for identifying victims in the oral health care environment.

Rapid physical assessment of the injured child

Traumatic injuries that involve the dentition and maxillofacial region may occur as isolated events in pediatric patients but are often associated with multisystem injuries and traumatic brain injuries. The primary trauma survey serves to identify and treat life-threatening injuries. The secondary trauma survey is a complete examination of the patient after the stabilization of physiological parameters. Frequent neurologic and physical assessments of the injured child are crucial to preventing deterioration. The role of the dental professional is to identify and refer for medical evaluation patients who present with concerning neurologic signs and symptoms after traumatic injuries to the maxillofacial region.

Patterns of ENT injuries in sports-related accidents

To evaluate sports-related ENT injuries regarding demographical trends of patients, location and mechanism of injuries, treatments required, and ability to return to sports activities, an observational study of patients was conducted. Each of the 120 participants in the study was evaluated in a private practice clinic. Males were injured more frequently, and the most common ages affected were 12 to 15-year-olds. Most injuries were the result of collision with other players or from impact of game balls, and most injuries occurred during sporting competitions. The most commonly injured structure was the nose. Most patients were managed medically and able to return to sporting activities quickly. While the most frequent mechanisms for sports injuries are not always preventable, health care providers should be aware of these trends described regarding types of sports commonly producing injuries and the predominant sites of injury to provide optimal care for athletic participants.

Orofacial injuries due to trauma following motor vehicle collisions: part 2. Temporomandibular disorders

Temporomandibular disorders (TMDs) following motor vehicle collisions (MVCs) may result from direct orofacial trauma but also occur in patients with whiplash-associated disorder (WAD) without such trauma. TMDs may not be identified at the time of first assessment, but may develop weeks or more after the MVC. TMDs in WAD appear to occur predominantly in females and can be associated with regional or widespread pain. TMDs following MVCs may respond poorly to independent therapy and may be best managed using multidisciplinary approaches.

Orofacial injuries due to trauma following motor vehicle collisions: part 1. Traumatic dental injuries

Dental providers must determine the presence of orofacial injury, and diagnose and treat dental and orofacial outcomes of trauma caused by motor vehicle collisions. Determination of causation and relation to the trauma is indicated. Dental trauma includes concussion, subluxation and dislocation of teeth, and fracture of teeth and maxillofacial bone, in addition to soft tissue injury that may cause ecchymosis, hematoma and laceration or abrasion. This article focuses on orofacial injury and dental complaints following motor vehicle collisions, while part 2 focuses on temporomandibular symptoms.

[Peculiarities of ballistic wounds of maxillo-facial area inflicted by modern ballistic weapon]

The article presents data of a comparative investigation of volume of ballistic damages of maxillo-facial area, given by different ballistic weapon (from usual PM to newest GSh-18). The article says that was set up a large volume of damages of sort and bone tissues of maxillo-facial area, given by bullet of cartridge of GSh-18 in all searched parameters. All materials, received in investigation, could be used in science substantiation and in elaboration of recommendations in planning of structure of sanitarium casualty, methods of investigations, surgical treatment and rehabilitation of wounded with damages, given by modern ballistic weapon.

What victims of domestic violence need from the dental profession

Most dental schools teach students about domestic abuse, but it is unknown if this information is ever applied in practice. This study was conducted to determine whether domestic violence victims 1) visited dental offices when signs of abuse were present; 2) were asked about their injuries; 3) were given referrals or assistance; and 4) want the abuse recognized by and discussed with the dental professional. A survey was developed and mailed to fifteen shelters. Eleven (73.3 percent) shelters participated, with a total of 112 out of 165 (67.8 percent) surveys returned. Descriptive statistics were analyzed, and an ANOVA test was conducted to determine if a relationship existed between the incidence of abuse and ethnicity. Seventy-six percent of respondents had suffered physical abuse in the head and neck area. Over half of the participants had seen a dentist when signs of abuse were present, yet 88.6 percent were not asked about their injuries. In addition, 69.2 percent responded that they would have liked to have been asked about their injuries. It appears that the dental profession needs to take a more active role in the recognition of domestic violence in their patient populations. Raising dentists and dental hygienists' awareness of the problem and potentially increasing the number of referrals may help more victims.

[Management of maxillofacial injuries in an emergency unit: our experience]

Maxillofacial injuries are relatively frequent. These may be complicated by cranioencephalic injuries or large facial wounds. We report our experience with the initial management of these lesions in an emergency unit setting. In 2007, we observed 105 patients with maxillofacial injuries. Maxillofacial injuries were associated with cranio-encephalic injuries in 69 patients (65.7%) and with polytrauma in 31(29.5%), while in 5 cases (4.8%) they were isolated. The main causes of trauma were motorcycle accidents (60%). All patients were treated in accordance with the Advanced Trauma Life Support guidelines and assessed by computed tomography. No mortality was observed after diagnosis in the emergency unit or in the month following the trauma. Seventy-seven patients (73.3%) were admitted and 28 (26.7%) were treated and discharged. Accurate diagnosis and appropriate initial management yield good clinical outcomes with functional restoration and fewer aesthetic complications.

[Assessment of the injury severity score in evaluation of multiple maxillofacial injuries]

OBJECTIVE

To compare the superiority of abbreviated injury scale (AIS) 2005 and AIS 1998 for evaluation of maxillofacial injury severity and major trauma outcome.

METHODS

A total of 450 trauma patients evaluated by AIS 2005 and AIS 1998 from July 2005 to January 2007 were analyzed retrospectively.

RESULTS

The mortality and morbidity of complications in trauma patients were ascending with the increase of injuries severity score (ISS). The ascending tendency in mortality was more notable in injuries severity score (ISS) > 20 in AIS 2005. The mortality in trauma patients in AIS 2005 was significantly lower than those in AIS 1998 in ISS > 15, < 20 (P = 0.001). The ascending tendency to morbidity of complications was more notable in other ISS groups in AIS 2005 than those in AIS 1998.

CONCLUSIONS

The evaluation of injury severity and major trauma outcome by ISS based on AIS 2005 is superior to based on AIS 1998. It is reasonable to definite severe trauma by ISS value greater than 20 in AIS 2005.

Management of a severe cranio-orbito-facial trauma with a dislocation of the globe into the maxillary sinus

We report two cases of severe cranio-orbito-facial trauma associated with a dislocation of the globe into the maxillary sinus. Simultaneous surgical repositioning the globe in the orbit and reconstruction of the orbital floor defect with an autogenous bone was performed in the first case. Postoperatively, the globe was in a normal position with a moderately reduced motility. The patient's visual acuity was reduced to light perception while indirect ophthalmoscopy was normal. In the second case, no surgery could be attempted because the patient never regained consciousness and died 7 days after the trauma. Although the visual prognosis of such conditions is usually considered to be extremely poor, avoiding primary enucleation and deploying all efforts to preserve the eye, aims at helping the patient to recover psychologically from the trauma and allows to improve her/his cosmetic aspect.

[Subcutaneous emphysema of the face, neck and upper mediastinum following a minor maxillofacial trauma]

Subcutaneous emphysema is the inadvertent introduction of air into tissues under the skin covering the chest wall or neck. The common causes of subcutaneous emphysema are rib fracture, parenchymal lung wound and esophageal trauma. Rarely, it occurs after oral and nasal surgery or maxillofacial trauma. We observed subcutaneous emphysema spread out from periorbital region to upper mediastinum in a patient presented to em e rgency department following minor maxillofacial trauma and admitted due to a simple fracture at his frontal maxillary wall. We present this present case to emphasize early initial management and close observation of minor facial traumas which can prevent further unexpected complications.

Diagnosis and management of common maxillofacial injuries in the emergency department. Part 4: orbital floor and midface fractures

Beware of the black eye! Orbital injuries are often missed or misdiagnosed. The underlying bony injury and or globe injury are often more serious than initial examination suggests.

A prospective study of dentoalveolar trauma at the Hospital das Clínicas, São Paulo University Medical School

PURPOSE

This prospective study evaluated the profile of patients with dentoalveolar trauma assisted at the emergency room of the Oral and Maxillofacial Trauma and Surgery Service at the Hospital das Clínicas, São Paulo University Medical School (Brazil).

METHODS

A prospective study by a questionnaire applied during the first attendance of those patients, in a period of eight months.

RESULTS

The collected data were statistically analyzed. It was observed that 4.7% of the patients that sought treatment at the Service had sustained dentoalveolar trauma and among these 74% were male. The most affected individuals were children aged 0 to 5 years and fall was the most prevalent etiologic factor. Avulsion and coronal/crown-root fractures were the most common types of dentoalveolar traumatic injures. As the age increases, the most common etiologic factors are traffic accidents and physical assault.

CONCLUSION

The incidence of dentoalveolar trauma decreased with age and the main etiologic factors in adult patients were traffic accidents and physical assault.

Application of MRI in indirect temporomandibular joint injury without condylar fracture

OBJECTIVE

To discuss the application of MRI in indirect temporomandibular joint injury without condylar fracture.

METHODS

MRI examination on temporomandibular joint was conducted in 28 patients with indirect injury to temporomandibular joint without condylar fracture. The scanning sequence included T(1)WI, PDWI on oblique sagittal section at both open and closed mouth positions, and T(1)WI, T(2)WI on oblique coronal section. The MRI appearance was analyzed by 2 senior radiologists.

RESULTS

Among the 56 temporomandibular joints of 28 patients, 35 joints exhibited pathological changes on MRI, in which there were 9 bone injuries, 21 articular disc dislocation, 24 intracapsular hematocele and hydrops.

CONCLUSIONS

MRI can clearly reveal bone injury, articular disc dislocation as well as articular capsule abnormality in the indirect injury of temporomandibular joint without condylar fracture. It is highly advocated in clinical use.

Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: Advanced trauma life support

Maxillofacial injuries are often seen in the emergency department. Fractures of the facial skeleton are commonly seen after assault, road traffic accidents, falls, and sporting injuries in a ratio mandibular:zygoma:maxillary of 6:2:1. Clinicians must be familiar with their management so that appropriate treatment may be used.

Craniofacial war injuries

In this paper, recent concepts in the management of war wounds of the maxillofacial region are described. A brief differentiation is also given between general practice medicine and military medicine.

Complex-type penetrating injuries of craniomaxillofacial region

Craniofacial traumas are one of the most common clinical events of the 21st century. The possibility of associated injuries of the head and neck may also determine functional and cosmetic problems in these patients. The most frequent pathologic conditions observed are contusions, lacerations, abrasions, avulsions, and the inclusion of foreign bodies. In particular, penetrating injuries represent a rare but complex variety of craniofacial trauma. Generally, the penetrating material is stiff enough to cross through different anatomic structures during a particularly violent collision caused by a road or work accident or during an attack. The therapeutic strategy adopted for this type of patient depends mainly on diagnostic procedures such as skull radiograms in different projections, computerized tomography, magnetic resonance imaging, and, occasionally, echotomography. However, on arrival at the emergency department, the clinical conditions of the patient will determine the type of investigation to be carried out. Last, to prevent any postoperative infections, wide spectrum antibiotic therapy is advisable. Ideally, imaging should be repeated postoperatively to confirm resolution of the initial clinical condition. In this article, the authors describe three unusual clinical cases of patients with penetrating injuries of the head and face together with the protocol adopted for treatment of such complex craniofacial injuries. The three cases described demonstrate that, despite the initial appearance of penetrating wounds, a correct diagnostic assessment followed by a suitable therapeutic protocol can reduce cosmetic and functional defects to a minimum.

[Assessment of traumatic tooth injuries in the emergency room]

Many patients with facial injuries are first seen by doctors in the emergency room. Injuries affecting teeth and alveolar process are common in children; approximately half of all children have sustained such an injury before adulthood. Dentoalveolar trauma does not pose a significant morbid risk for the trauma patient. However, failure to recognise or obtain appropriate consultation can result in premature tooth or alveolar bone loss, resulting in problematic prosthetic rehabilitation. Emergency room doctors should know the initial treatment guidelines for traumatic dental injuries to provide optimal treatment before the patient can seen by a dentist. An avulsed tooth should be replanted immediately, or kept moist until it can be replanted. Prognosis is related to storage media and the length of the extra-alveolar period. Teeth replanted within 5 minutes have the best prognosis. If the primary consultation is by phone the patient, or the parent, should be informed to replant the avulsed tooth. If this is not feasible the tooth should be stored in milk, saliva (oral cavity) or physiologic saline until replanted. Primary teeth are not replanted.

Application of a Facial Injury Severity Scale in Craniomaxillofacial Trauma

PURPOSE

To establish a Facial Injury Severity Scale (FISS) that correlates with patient outcome and provides a practical tool for communication between clinicians and healthcare personnel for management of facial trauma.

PATIENTS AND METHODS

All patients presenting to the Emergency Department (ED) at Legacy Emanuel Hospital (Level One Trauma Center) in Portland, Oregon between 01/1993 and 6/2003 with facial fractures with or without concomitant non-facial injuries where identified retrospectively. The diagnosis and treatment of all facial fractures were conducted by the Oral and Maxillofacial Surgery (OMFS) service. The following data were collected; age, gender, mechanism of injury, detailed diagnosis of facial fractures, disposition, and the length of hospital stay (LOS). The hospital operating room charges (ORC) for the treatment of each patient's facial fractures were also obtained. We designed the FISS to be a numeric value composed of the sum of the individual fractures and fracture patterns in a patient. Not all fractures of the face are weighted equally in the FISS because not all fracture patterns are equal in severity. Individual fracture points within the scale were optimized to result in the highest correlation.

RESULTS

A total of 1,115 patient admissions to the ED with blunt or penetrating maxillofacial injuries were identified and reviewed. Full information on operating room charges (ORC) was available for 247 patients (average age: 32, SD +/- 17; range, 2 to 84; male:female, 3:1; blunt:penetrating, 232:15). The FISS scores were calculated for each patient (average FISS: 4.4, SD +/- 2.7; range, 1 to 13). Hospital ORC for the treatment of each patient's maxillofacial injuries were obtained from the hospital financial services (average ORC: 4,135 dollars, SD +/- 2,832 dollars; range, 845 dollars to 18,974 dollars). A significant correlation was identified between the FISS and the ORC (R value = .82). The length of stay was significantly associated with the FISS (t = 4.7, 245 degrees of freedom, P = .000004). Although the association was statistically significant, FISS is not a very good predictor of length of stay. The correlation between the predicted and observed values was 0.38. There were 3 deaths among the 247 entries. Those 3 deaths had higher than average FISS scores, but the difference between the scores of survivors and non-survivors was not significant (P = .08). The number of deaths was small and a larger study would be required to resolve this question.

CONCLUSIONS

We introduce a FISS that is easily calculated and reliably predicts the severity of maxillofacial injuries as measured by the operating room charges required to treat the facial injury. The scale is also an indicator of hospital length of stay. We anticipate this to be a valuable tool for assessment and management of maxillofacial trauma.

[Tactics in rendering of specialized medical care to the casualties with combined maxillofacial trauma]

Basing on the clinic's data obtained during the 5-year period (2000-2004) we observed 653 patients with different traumas of maxillofacial area. Among the patients 69.8% were the casualties with mandible fractures, 6.7--with maxilla fractures and 2.5%--with zygomatic bone fractures. The combined injuries of maxillofacial and other areas were observed in 11.6%. The combined injuries of maxillofacial area with extremities constituted 0.6%, with chest--0.5% and adjacent areas of head--9.5%. The analysis of conducted therapeutic work and previous experience allows suggesting the medical tactics concerning the problems of terms, methods and volume of specialized care rendered to the patients with combined maxillofacial trauma. It implies that combined injury of jaws with other body segments requires rendering of specialized care in whole volume, early periods, just immediately after getting the patient from shock.

Dentoalveoläre Traumen

PURPOSE

The purpose of this study was to evaluate the overall place of dental trauma in facial injuries. This was a retrospective investigation based on the analysis of a large amount of dentoalveolar injuries over a 10-year period.

PATIENTS AND METHODS

Between 1991 and 2000, 4763 of 9543 patients suffering from oral and maxillofacial injuries, sustained dentoalveolar trauma. Records of 6237 different dental injury patterns were reviewed according to the five main injury mechanisms: age, sex, type of injury, cause of accident, and frequency of dentoalveolar trauma. They were statistically analyzed using frequency distribution, chi-square test, t-test, Mann-Whitney U test, Kolmogorov-Smirnov test, and logistic regression analysis.

RESULTS

Household and play (2117), sports (1533), traffic accidents (438), acts of violence (426), and work-related accidents (201) were noted. A total of 4763 patients had 2988 subluxations, 2356 showed crown fractures, 444 had avulsions, 176 root fractures, 154 intrusions, and 119 patients suffered from concussions. This number of patients accounts for the prevalence of 49.9% for dentoalveolar trauma among all facial injuries.

CONCLUSION

Only the analysis of a large number of injuries reveals the risk of suffering from dentoalveolar trauma. Due to this fact, preventive methods can be recommended and demanded more effectively.

[Sports and orofacial injuries]

Many people enjoy sports, it is healthy and relaxing. There is, however, an inherent risk of sustaining injuries and fractures of the maxillofacial skeleton. Adequate diagnostics and treatment are mandatory to minimize the possible long-term consequences of injuries. Dentists may become primary involved in the diagnosis of such traumas, particularly when injuries are limited to the orofacial region. In addition, they can play an important role in caring for sportsmen with orofacial injuries, for instance by endodontic, restorative, and prosthodontic treatments. This paper discusses the assessment and treatment of fractures of the mandible, the zygoma, the mid-face, the orbital bones, the nose, and the frontal sinus. The assessment must followed by treatment as soon as possible. Treatment options of orofacial fractures are conservative treatment by exercising and/or oral splints and surgical reposition, either or not using osteosynthetic materials.