Maxillofacial trauma in a pregnant patient: Contemporary management principles with a case report & review of literature

Trauma during pregnancy deserves special attention because of its management objectives, i.e. well-being of both pregnant woman and foetus. Maxillofacial trauma directly affects the nutrition of foetus by interfering with the normal functions in a pregnant woman such as mouth opening, mastication and breathing. Hence early restitution of form and function of maxillofacial skeleton is essential. However, the gravid status is associated with numerous anatomical and physiological changes which present with clinical dilemma related to imaging and treatment. A careful scrutiny of the patient's systemic and gestational status is absolutely essential before, during and after instituting any interventional procedures. We present a case of bilateral condyle fracture in a 30-year-old pregnant woman in the third trimester (32 weeks). She was treated with inter maxillary fixation using orthodontic brackets & elastics. After successful restitution of occlusion, the patient was advised aggressive physiotherapy which ensured normal mouth opening. Two weeks later, the patient delivered uneventfully. The patient was followed up at one month and 3 month and demonstrated restitution of normal occlusion, mouth opening and lower facial height. This article aims at analyzing the contemporary principles in management of maxillofacial trauma in a pregnant woman and clarifying the common misconceptions.

Epidemiological pattern of maxillofacial fractures in northern China: A retrospective study of 829 cases

This study was performed to examine the epidemiological features of maxillofacial fracture, including the incidence, causes, age and sex distribution, methods of treatment, and prognosis, in a local area.A retrospective study was performed to investigate the epidemiological characteristics of 829 patients with maxillofacial fractures treated in a hospital in northern China from August 2011 to July 2019. Sex, age, etiology, fracture site, and treatment method were obtained from the medical records.The average age of all 829 patients was 36.1 years, and most patients were in the 20- to 29-year age group. The male to female ratio was 3.04:1.00. Traffic accidents were the main cause of the maxillofacial fractures. The mandible was the most commonly fractured bone, and the parasymphysis was the most frequently affected site. Head injury was the most common associated injury. Open surgery with internal fixation was the first-choice treatment for most cases.Traffic accidents were the main cause of maxillofacial fractures, followed by falling. Open surgery with internal fixation was the leading treatment choice. Both functional and esthetic outcomes should be considered in the treatment of maxillofacial fractures.

Oral motor and electromyographic characterization of adults with facial fractures: a comparison between different fracture severities

OBJECTIVES:

To characterize the oral motor system of adults with facial injuries and to compare the oral motor performance/function between two different groups.

METHODS:

An observational, descriptive, cross-sectional study was conducted in 38 patients presenting with facial trauma who were assigned to the Division of Orofacial Myology of a Brazilian School Hospital. Patients were divided into two groups: Group 1 (G1) consisted of 19 patients who were submitted to open reduction of at least one facial fracture, and Group 2 (G2) consisted of 19 individuals who were submitted to closed fracture reduction with maxillomandibular fixation. For comparison purposes, a group of 19 healthy volunteers was recruited. All participants underwent a clinical assessment that included an oral motor evaluation, assessment of the mandibular range of motions, and electromyographic assessment of the masticatory muscles.

RESULTS:

Clinical assessment of the oral motor organs indicated that G1 and G2 presented deficits related to the posture, position, and mobility of the oral motor organs. Patients also presented limited mandibular ranges of movement. Deficits were greater for individuals in G1, especially for maximal incisor opening. Additionally, patients in G1 and G2 presented a similar electromyographic profile of the masticatory muscles (i.e., patients with facial fractures presented lower overall muscle activity and significant asymmetrical activity of the masseter muscle during maximum voluntary teeth clenching).

CONCLUSION:

Patients in G1 and G2 presented similar functional deficits after fracture treatment. The severity of facial fractures did not influence muscle function/performance 4 months after the correction of fractures.

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].

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.

[Modern aspects of combat maxillofacial trauma (review of foreign scientific-medical publications during 2012-2013)]

The current article is dedicated to the modern aspects of combat maxillofacial trauma as they have been presented in 2012-2013 scientific publications. It has been shown that due to employment of more and more powerful explosive devices the facial trauma over the last decade has occurred more frequently and become more severe. Some new methods of facial injuries treatment are being tested now, among them KSL-W antimicrobial decapeptide, new bone regenerative biocompatible materials, scar-healing mesenchymal and adipose-derived stem cells, and a custom automated face dressing platform.

Significance of osteoporosis in craniomaxillofacial surgery: a review of the literature

Osteoporosis is a common problem in orthopedic surgery. The purpose of this review of the literature was to examine whether osteoporosis is also an important factor in patient treatment in the field of craniomaxillofacial surgery. Emphasis was given to the consequences of osteoporosis for the maxilla and mandible, the influence of osteoporosis on fracture treatment, the use of dental implants, the importance of soft tissues and the effect of osteoporosis therapies. It was found that osteoporosis does affect the bones of the skull. The effect of osteoporosis on treatment, however, is controversial and necessitates better ways of quantifying bone loss. Large inter-individual and site-specific differences in bone density, as well as other effects such as removal of teeth, periodontitis, implant insertion, augmentation procedures and altered loading with dystrophic consequences need to be considered in future studies. Special attention should be given to osteoporosis during fracture treatment.

A new model of blast injury from a spherical explosive and its special wound in the maxillofacial region

OBJECTIVE

The goal of this study was to establish an efficient explosive model with spherical explosives for the study of blast injury and its wound characteristics in the maxillofacial region.

METHODS

Different spherical explosives were used to produce blast waves and to establish the wound model. Fresh sheep heads as the targets were used for the study of wound characteristics. The wounding parameters and the injuries of targets after explosion were observed.

RESULTS

The overpressure values of blast waves decreased exponentially along with the increase of distances to explosives and so did the tissue damage. The blast injury is quite different from other injuries and is more serious. A kind of special "split fracture" of the mandibles was found.

CONCLUSIONS

The new explosive wound model with spherical explosives can be used for the study of blast injury in the laboratory. The injury manner of blast wave and the local anatomy of tissues resulted in the special wound characteristics.

[Morphogenic processes in dosed distraction]

Dosed distraction of bone regenerate is paralleled by distraction of soft tissues (skin, muscles, nerves, etc.), which is particularly obvious during liquidation of medium-sized and extensive mandibular defects. Such distraction of soft tissues leads to their regeneration and growth. However regeneration of soft tissues is paralleled by dystrophic processes, which are never observed in bone regenerate. Dosed distraction can be used in repair of combined bone and soft tissue defects and deformations of the face of different etiology.

Maxillo-facial trauma

Injuries to the facial bones, orbits and adjacent soft tissue structures are common. Despite the increasing safety precautions in modern cars, facial injury is very often caused by motor vehicle accidents. Severe trauma to the face is a strong indication for radiological investigation. In the patient with maxillo-facial trauma, the radiological exploration of should answer two major questions: do the fractures involve areas that may alter the physiologic function of the sinuses, mouth, nasal vault or orbit?, and will the fracture result in any cosmetically detectable abnormality? The goal of the radiological work-up is to define the number and exact location of the fractures, to determine if there is any depression, elevation, or distraction of the fracture fragments, and to assess concomitant soft tissue complications. In this article, we review the role of clinical evaluation, plain X-rays, computed tomography (CT) and magnetic resonance imaging (MRI). Imaging findings are correlated with anatomic and physiopathologic considerations. We present a practical classification system of facial trauma, with emphasis on trauma of the paranasal sinuses and facial bones (nasal and tripod fractures, Le Fort fractures) and orbits (foreign bodies, soft tissue and orbital wall injuries such as blow-in and blow-out-, lateral wall- and apical fractures). A third part focuses on trauma of the mandible and the temporomandibular joints.

Critical systemic and psychosocial considerations in management of trauma in the elderly

Traumatic injuries in the elderly are increasing commensurately with the activeness and healthiness of the lifestyles seen in our expanding geriatric population. Census data suggest that the elderly population will expand by 50% in future years and will represent a larger percentage of Americans by the year 2050. The annual occurrence of traumatic injuries in the elder cohort is reported to be as high as 29%. Perioperative management of acutely injured elderly patients is different from the care rendered to younger patients and is typically more complex. The purposes of this article are to (1) review factors related to aging that may have profound effects on the care and outcomes of senior citizens with craniofacial trauma, (2) consider the perioperative medical evaluation of the older patient, (3) discuss nutritional support and anesthetic management in the elderly, (4) discuss the unique physiological factors that may influence the treatment of craniofacial trauma in older patients, and (5) provide a rationale for facial trauma repair in the elderly that is influenced by the risk-benefit outcome of treatment planning decisions.

[The pathogenesis of combined maxillocerebral trauma]

Study of the systemic and regional blood pressure in various parts of the maxillofacial area and of microcirculation in tissues and fundus oculi in patients with maxillofacial injuries showed that such traumas involve brain injuries in 100% of cases and are therefore combined. The authors emphasize that this patient population is to be treated for brain injuries.

[Osteoinduction and -reparation]

Traumata, diseases, developmental deformities, and tumor resections frequently cause bone defects and atrophies. In general, three different mechanisms exist by which bone restoration can be achieved: (1) osteogenesis initiated by vital, osteoblastic cells of autografts; (2) osteoconduction (or creeping substitution); and (3) osteoinduction. The latter mechanism means the differentiation of pluripotent, mesenchymal-type cells (located in a recipient bed with strong regenerative capacity) into cartilage- and bone-forming progenitor cells under the influence of inductive bone morphogenetic proteins (BMPs). Some BMPs are physiologically included in low concentrations as organic components in bone tissue. They can diffuse from demineralized bone implants into the recipient bed and induce a differentiation into new bone tissue. Nine different BMPs have been isolated, characterized, and cloned. Some of these possess inductive properties and can initiate new bone formation in muscle tissue or in bone defects. In the future recombinant BMPs will be available in unlimited quantities. This will lead to completely new therapeutic concepts in reconstructive bone surgery.

[Efficacy and tolerability 80 mg granulated ketoprofen lysine salt in posttraumatic orodental pain: double blind vs placebo study]

A randomized, double-blind parallel group, placebo-controlled study was carried out in order to evaluate the analgesic and antiin-flammatory activity of ketoprofen lysine salt as granular formulation. Sixty patients undergoing extraction of an impacted third molar were treated orally with 80 mg ketoprofen lysine salt sachet or placebo t.i.d. for 3 days. The inflammation related local signs (pain, flare, local heat and wheal) were evaluated by scores at 1th and 3th day of observation; to study the time-course of analgesic activity, pain intensity was evalauted by Visual Analogic-Scale (VAS) by Scott-Huskisson before and 0.30 minutes, 1, 2, 3, 4, 5, 6, 8 hours after the first administration. Ketoprofen lysine salt was significantly superior to placebo in reducing all inflmamtory signs and symptoms starting from the first day of treatment; the analgesic effect was evident already 30 minutes after administration. Investigator's and patient's global evaluations of efficacy resulted favourable for ketoprofen lysine salt in 96.6% and for placebo in 26.7%. The three adverse events reported were limited to gastric pyrosis (ketoprofen lysine salt, two patients; placebo one patient) and posed no problem to patient management. These data demonstrate the pronouced and rapid analgesic and antinflammatory activity of 80 mg ketoprofen lysine salt granular formulation in post-operative pain and inflammation associated with dental surgery.

[Post-traumatic myo-arthropathy of the mandibular joint. Report of a case]

The author reports a case of post-traumatic myoarthropathy which was resolved through the search for a new centric ratio which was subsequently transformed in ICP with a varied vertical dimension. This was based on the assumption that post-traumatic intracapsular modifications impose this therapeutic objective given that they do not fall within the range of muscular adaptability.

Early management of multiply injured patients with maxillofacial injuries transferred to hospital by helicopter

It has been suggested that early intensive medical treatment will improve the outcome for trauma patients with severe injuries. A Helicopter Emergency Medical Service (HEMS) based in an urban area was inaugurated by The Royal London Hospital. Specially trained medical and paramedical personnel flew with the helicopter to accident scenes. On return to the hospital, multi-disciplinary teams, including maxillofacial, were called to manage the patients. Operations from its own helipad commenced from the end of August 1990. A retrospective study of 192 patients transferred by HEMS to the Royal London Hospital during 16 months was undertaken. 18% (34) patients had facial injuries recognised at primary and secondary surveys according to Advanced Trauma Life Support (ATLS) protocols. The problems of early management are described and routine techniques for the control of haemorrhage from the maxillofacial area were developed.

Impact tolerances of the rigidly fixated maxillofacial skeleton

A study was designed to determine how soon an athlete who undergoes rigid fixation of a facial fracture can return to full competition. The impact resistance of a rigidly fixated malar complex fracture was studied and compared with that of an intact malar complex. Twelve fresh human cadaver heads were used. A custom-designed impact device was used to deliver a blow of a specific energy to each intact malar complex. The subsequent fractures were rigidly fixated at three points using titanium miniplates and screws. A second impact of identical energy was delivered. The forces generated and the subsequent displacement of hard and soft tissues were recorded after each impact. It was concluded from this study that an impact to a rigidly fixated malar complex fracture produced less force and greater displacement of hard and soft tissues than an impact of identical energy to an intact malar complex. The potential for sustaining more severe maxillofacial injuries after an initial facial fracture should be seriously considered. The results suggest that sufficient time should be allowed for the bony healing of a facial fracture to occur, even after rigid fixation, before an athlete can resume full contact activities.

Strategies for the study of long-term sequelae of oral and facial injuries

Measurement of morbidity after orofacial trauma is necessary to monitor progress and to enable decisions to be made concerning surgical intervention, compensation awards, and psychological support. Although some measurements are routinely made in the assessment of recovery after trauma, many are still in a developmental phase or have only been used in research work. There is a need for a rational, comprehensive, quantitative means of assessing morbidity after orofacial trauma. Such assessments need to include measures of social and psychological distress, as well as physical abnormalities. This article reviews available methods of measuring morbidity and identifies areas in which new methods and developments are necessary. This quantitative approach to the assessment of trauma patients is consistent with developments in traumatology and psychology, which include injury severity scoring and the use of psychomatic tests. A scoring system for assessing orofacial deformity and disability and the attendant psychosocial distress appears to be an attainable objective.

Methods of rigid fixation

Rigid fixation has been an exciting and major advance in maxillofacial surgery. Further studies will elucidate how much strength is necessary to achieve the proper amount of fixation necessary in each region of the facial skeleton. This information coupled with improvements in design will allow production of the lowest-profile implants possible for each area of the craniofacial skeleton. An exciting future possibility is construction of rigid fixation systems made of resorbable plates and screws. Research is in progress to find methods of constructing a system that incorporates the proper rate of resorption, the necessary strength, and precisely constructed plates and screws.

[Psychogenic pain sensations in teeth, mouth and jaws]

Pain is always a subjective experience. Therefore the term "psychogenic pain sensation" seems to be a pleonasm at first sight. In fact, however, the dentist's attention should not only be focussed on the removal of the objective causes of pain, but the fact itself, i.e. the patient's subjectivity, must be considered, too. Unless this is done, the results are serious diagnostic and therapeutic errors.

[Growth disorders following fractures of the midface in children]

12 patients who had suffered mid face fractures during their childhood were examined for skeletal deformities of the facial skull. The cephalometric data showed that neither the position nor the inclination of the maxilla were significantly different from normal anatomy. No correlation was found between the age, the severity of injuries and surgical treatment and resulting deformities.

Management of low-caliber, low-velocity gunshot wounds of the maxillofacial region

Low-velocity, low-caliber missile wounds have a wounding profile different from that of high-velocity, high-caliber missiles. The pathophysiology of these types of injuries is discussed. Care for such injuries should be conservative.

Low velocity hand-gun injuries of the maxillofacial region

In contrast to the number of reports in the literature describing high velocity injuries of the maxillo-facial region, there are relatively few which deal with civilian type gunshot injuries. The purpose of this study was to undertake a retrospective analysis of 40 cases of low-velocity hand-gun injuries of the maxillo-facial region. The majority of cases were due to assault followed by accidental shootings and failed suicide attempts. Injuries ranged from mild soft tissue damage without fractures to severe, comminuted fractures of the facial bones. In some cases, soft tissue damage was severe. Rarely were injuries life threatening. Entrance wounds were characteristically small and well circumscribed. In 60 per cent of cases the bullet did not exist and was retained within the tissues. The floor of the mouth and tongue were the soft tissues most commonly injured. Other structures injured were major blood vessels, nerves and the eye. Mandibular fractures occurred in 58 per cent of cases, followed in frequency by maxillary complex fractures. Twenty per cent of fractures simultaneously involved bones of the upper, middle and lower-thirds of the facial skeleton. The above injuries are discussed and a classification of low-velocity hand-gun injuries of the maxillo-facial region is proposed.

The syndrome of inappropriate secretion of antidiuretic hormone in the maxillofacial trauma patient

The maxillofacial trauma patient whose neurologic status undergoes a rapid and serious deterioration may have a severe hyponatremia secondary to the inappropriate secretion of antidiuretic hormone (SIADH). Other causes of hyponatremia must be ruled out, especially posttraumatic cerebral salt wasting, which necessitates a different mode of therapy. A case of SIADH is reported, and the work-up and differential diagnosis of posttraumatic hyponatremia are discussed.

Experimental and clinical results of new advances in the treatment of facial trauma

Theoretical considerations and photoelastic and mechanical experiments showed us the progression from metal wires to metal plates in different systems. In the midface there is no question about stabilization by miniplate systems. For mandibular fracture treatment, there is a discussion going on at present about the use of stable maxisystems versus less stable minisystems. Our clinical experience of 15 years indicates that there is no further demand for strict stable fixation of mandibular fractures, and we were encouraged to use less stable systems with similar good results, as our follow-up and statistical evaluation showed. To continue the simplification of osteosynthesis methods we are performing experiments with resorbable materials. Early results show fracture healing comparable with that found with plate-and-screw systems. Our clinical experience has shown that there is no longer any question about the ability of stable fracture treatment by means of osteosynthesis. However, there still is the question of how functional such fracture treatment might be.

Civilian maxillo-facial gunshot injuries

Recently, in many parts of the world, there has been an increase in the number of civilian crimes involving guns and nowadays any oral surgeon in hospital may be confronted with this type of injury. This paper reviews the mechanism of wounding by different firearms to allow an appreciation of their effect on living tissues, and then outlines the clinical management of these injuries.