Mini-retromandibular access to the condyle in panfacial fractures

ABSTRACT: Surgical management of panfacial fractures can be extremely challenging. The many fracture lines and lack of landmarks make it difficult to restore the facial skeletal morphology. Extracapsular fractures of the mandibular condyle require open reduction and internal fixation to restore the vertical and sagittal dimensions of the mandible, representing the base for further facial skeleton reconstruction. Six patients with panfacial fractures, including a bilateral extracapsular condylar fracture, were treated between January 2006 and November 2009. One patient underwent surgical procedure 60 days after the injury. The condylar fractures were treated via a mini-retromandibular access. Overall, the bone morphology restoration was good. In particular, all of the condylar fractures were reduced satisfactorily. No complication was detected, and no facial nerve lesion was observed. The literature contains many proposals for surgically accessing panfacial fractures. Open reduction and internal fixation of condylar fractures are crucial for restoring face height. The mini-retromandibular access is especially suitable, because it allows safe, rapid surgical management.     

Secondary reconstruction of panfacial fractures

Introduction

Although the primary management of patients with panfacial fractures has been well discussed in the medical and dental literature, secondary management of those patients who were not treated or were incompletely treated has not been as well addressed.

Purpose

The purposes of this paper are to review the basic concepts of panfacial fractures and to address the secondary reconstruction of patients whose primary management was less than ideal.

Discussion

In this paper, we present three cases of secondary reconstruction of the maxillofacial skeleton following complicated panfacial fractures. We also discuss the challenges that exist in treatment planning and executing treatment in these complex cases.     

Avoidance of implicit hazards: the realignment of maxillary and mandibular arches in comminuted and facial fractures

The authors introduce an attempt to elevate the problem of proper realignment of the maxillary and mandibular arches to achieve an exact transversal width of the lower third of the face with an index of the sum of the maxillary and mandibular central incisors, together with a new Artex-Callotte System (Karl Storz GmbH, Tuttlingen, Germany). This allows individual and anatomically correct restoration of the dental arches. This is especially helpful if either a large number of teeth or portions of dental alveolar processes have been lost in comminuted panfacial fractures. In addition, a sequential, step-management concept of comminuted panfacial fractures is described and illustrated. The goals of treatment with this method are to reestablish the midfacial height and projection and the occlusion, and reestablish the integrity of the nose, the orbit, and the transversal dimension of the lower jaw. This simple method is not yet well appreciated.     

Sequential surgical treatment for panfacial fractures and significance of biological osteosynthesis

Abstract –  The goal of this retrospective study was to evaluate the efficacy of panfacial fracture repair and to review guidelines for treatment based on AO/Arbeitsgemeinschaft fuer Osteosynthesefragen Association for Study of Internal Fixation theories of biological osteosynthesis. Sixty-eight patients with panfacial fractures were subjected to preoperative X-ray cephalometric analysis and model surgery, followed by open surgical reduction, rigid internal fixation and at least 8 weeks of clinical follow up. A variety of surgical approaches were used, with the 68 patients undergoing a total of 93 surgical procedures. In all but eight patients, the treatment produced satisfactory correction of maxillofacial deformities and restoration of normal function. Among the eight patients whose treatment was not deemed successful, there were two whose facial deformities were not corrected by treatment. In addition, there were five patients with enophthalmos or motor disturbance of the eye that failed to show improvement during the study, and four patients who exhibited signs of limited mouth opening and malocclusion. The systematic and sequential choices of surgical methods were key factors in determining panfacial fracture treatment outcomes. We propose that treatment of bone fractures must take into account the biological characteristics of the damaged bone to facilitate selection of appropriate plate and screw systems and repositioning methods.     

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目的    探讨全面部骨折各种手术复位径路的可行性及优缺点。方法    对2002—2009年在宿州市立医院口腔颌面外科救治的资料完整的69例全面部骨折手术病例复位手术径路进行回顾性分析。结果    69例患者中,有47例采用了头皮冠状切口+小切口,22例单纯采取局部小切口。术后随访平均6个月,患者在功能上皆取得了良好的治疗效果,并发症表现各有不同。结论    冠状切口+小切口和单纯局部小切口在不同适应证中均可获得满意的治疗效果,应进一步研究如何减少冠状切口的并发症和如何应用微创切口对全面部骨折进行良好复位。     

全面部骨折的诊治进展

全面部骨折主要指面中1／3和面下1／3骨骼同时发生的骨折。由于颌骨维持着面部的外形和轮廓，一旦发生全面部骨折，面部外形则遭到严重破坏，常伴发颅脑损伤且常合并胸腹脏器和四肢伤。因此，全面部骨折的诊治一直是颌面部创伤外科研究的重点和难点，其诊治原则及方法仍存在不少争议。本文就全面部骨折诊断和治疗的进展作一综述。     

Faciomaxillary fractures in north India. A statistical analysis and review of management

An analysis of the incidence of facial fractures and their combinations is presented along with an evaluation of our techniques of fracture reduction and fixation. Two hundred and sixty two patients with facial fractures treated between January 1982 and December 1983 at the Postgraduate Institute of Medical Education and Research, Chandigarh, form the basis of this study. Simple methods have been used for reduction and fixation for the last 20 years without any major modification, as they have provided satisfactory results. Road traffic accidents are the leading aetiological factor in both sexes. More than 75% of the cases were in the 16-45 year age group. The mandible was the most frequently fractured bone. Contrary to previous reports we found that the parasymphseal region was more commonly fractured than the subcondylar region. More than 50% of the maxillary and zygomatic fractures were a part of the panfacial group. Orbital and nasoethmoidal fractures were relatively uncommon.     

Splint-assisted reduction of comminuted or complex maxillofacial fractures

The aim of the study was to obtain anatomic bone healing and restoration of the patient's premorbid occlusion in complex facial fractures or comminuted facial fracture. Ten patients who applied to a tertiary health care clinic with complex or comminuted fractures, and mandibular fractures combined with condylar fractures which may impair the occlusal harmony were included in the study.After the preparation of premorbid occlusal splints and direct bonded orthodontic brackets, splint-assisted reduction and internal fixation have been performed. The treatment protocol was completed with 4 to 6 weeks of intermaxillary fixation over the splint. All fracture lines showed complete bone healing, without major complications requiring further treatment. Complications included a minor degree of malocclusion in one of the panfacial fracture patients and slight avascular resorption of the condyle in one of the avulsive open comminuted mandibular fracture patients.Using orthodontic splints and direct bonded brackets to obtain and maintain delicate reduction is an efficacious method for the prevention of occlusal disharmony and aesthetic impairments in comminuted lower facial unit and complicated facial fracture patients.     

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提要： 全面部骨折特指面中1／3 和面下1／3 的骨骼同时发生的骨折。全面部骨折除有严重的局部损伤外，常伴发颅脑伤以及全身多个器官损伤，救治中不仅要考虑局部因素，更要涉及初期急救时系统损伤救治的相关问题。因此，初期救治中应遵循标准的急诊创伤处理ABCs法，首先救治危及生命的损伤，然后尽早实施专科确定性手术治疗。术前应有明确的影像学诊断，精确了解骨折部位、骨折段移位情况。遵循良好显露，直视下骨折复位，坚强内固定的手术原则。本文根据作者的临床经验，简要评述全面部骨折的治疗原则和方法要点。     

可吸收钉板在上颌骨及全面部骨折中的应用

目的　评价可吸收钉板在上颌骨与全面部骨折中的应用。方法　选择2011年6月至2018年7月在武汉大学口腔医院口腔颌面创伤与颞下颌关节外科接受治疗的涉及上颌骨骨折的患者244例。全面部骨折的纳入标准是同时包含上颌骨骨折、颧骨颧弓眶骨骨折和下颌骨骨折。所有患者均主动要求使用可吸收钉板系统进行内固定。对其人口统计学信息、治疗情况和随访结果进行回顾性分析。结果　244例患者的上颌骨骨折部位全部使用可吸收钉板进行内固定，其中男145例，女99例；年龄6～73岁，平均35岁；上颌骨Le FortⅠ型骨折36例，Le Fort Ⅱ型骨折111例，Le Fort Ⅲ骨折型97例。涉及额骨骨折3例，鼻骨-眶-筛骨（NOE）复合体骨折42例，上颌骨矢状骨折37例，全面部骨折36例。全面部骨折患者中，颧骨颧弓眶骨、上颌骨、下颌骨同时使用可吸收钉板固定的有14例；仅颧骨颧弓眶骨、上颌骨同时使用可吸收钉板固定的有6例；仅颧骨颧弓眶骨使用可吸收钉板固定的有14例；另外2例患者的情况与上述三种分类均不符合。所有患者术前均有面部畸形，且出现咬合紊乱。复位和修复全面部骨折的方法按照“由简单到复杂”进行序列复位固定的原则。术后并发症情况：3例轻度错牙合畸形，1例颧骨部分缺损，1例眼球内陷，4例创伤瘢痕，2例眼睑下睑萎缩，2例颞肌萎缩。结论　灵活应用可吸收钉板进行上颌骨及全面部骨折复位固定具有可行性。软组织问题引起的手术后并发症，包括撕裂和不对称，难以避免。     

Submental intubation in panfacial injuries: our experience

Abstract –  Panfacial fractures present a unique set of problems to the anaesthesiologist and surgeon. Airway management in panfacial fractures is still a challenge to the anaesthesiologist as all modalities available such as orotracheal intubation, nasotracheal intubation, tracheostomy, etc., have their own advantages and disadvantages. When all the conventional modalities to secure airway seem unsuitable then submental route offers an excellent alternative to manage airway in such patients. Here we describe our experience with submental intubation technique in 10 patients with panfacial injuries over a period of two years.     

三维定位面弓的设计及其在颧骨骨折复位中的应用

目的:设计研制三维定位面弓,并对其用于颧骨骨折的术前诊断、术中复位校准以及术后效果进行评价。方法:设计并制作可用于测量颧骨突度、面侧方宽度以及眼球突度的三维定位面弓,用于颧骨颧弓粉碎性骨折和陈旧性颧骨骨折共5例,评价其临床应用效果。结果:开发并研制出可用于测量颧骨前突度、面宽和眼球突度的三维定位面弓,通过对5例颧骨骨折患者的临床应用,效果满意。结论:三维定位面弓是颧骨不对称畸形的定量测量工具,可用于术前颧面部软组织畸形诊断、术中复位指导和校准,以及术后面部对称性评价,还可用于眼球突度的测量。     

Jaw fractures in Enugu, Nigeria, 1985-95.

A retrospective analysis of 900 patients with jaw fractures of the facial bones during the period January 1985 - December 1995 indicated that 747(83%) resulted from road traffic accidents, 75(8.4%) from interpersonal violence, 39(4.3%) from accidents during sporting events, and 36(4%) from occupational accidents, while the causes of 3(0.3%) were not stated. The left side of the face was affected more often than the right. The mandible was twice as likely to be fractured as the zygomaticomaxillary complex. The symphysis-body-angle and the condylar region were the most common sites of fracture of the mandible, while the zygoma was the area most often affected in the middle third of the face. Most maxillofacial fractures occurred in the age group 21-30 years, and the lowest among those over 60. Three times as many men were affected as women. We conclude that there is high incidence of fractures of the facial bones caused by traffic accidents in our environment and, in all age groups, men were more likely to be affected than women.     

Classification of malar complex fractures using computed tomography

Fifty-one patients with malar complex fractures were examined with computed tomography to analyze the pattern of displacement in an anteroposterior direction of the face. Malar complex fractures were classified into four groups according to the location and direction of the fragments. Comparisons of the fracture classification obtained by use of CT images with that obtained by conventional radiographic methods demonstrated sufficient correlations between the classification systems to confirm that it is possible to establish a complete three-dimensional pattern of displacement in malar complex fractures using CT imaging.     

Maxillofacial fractures sustained in bicycle accidents

The present report is an analysis of 93 patients (52 male; 41 female) treated in 1981-1983 for maxillofacial fractures sustained in bicycle accidents. These accidents accounted for 7.1% of all facial bone fractures treated during the same period. Most accidents were single vehicle accidents (88%) and took place during the summer months. Of the patients, 65% had mandibular fractures, 35% had midface fractures and 5% had fractures in both the middle and lower thirds of the face. Condylar fractures were by far the most common of the mandibular fractures (67%)--a result which differs from studies concerning the profile of mandibular fractures in general. The majority of the middle third fractures were zygomatic (65%). Multiple injuries were diagnosed in 38% of the cyclists and other head injuries were the most common associated injury. Mean hospitalization of the in-patients (38%) was 4.1 days and the average sick leave was 14 days. The results of the study indicate that the use of protective helmets should be strongly recommended to cyclists, although most commercially available helmets do not protect the whole facial area and especially not the chin.     

Open reduction and internal fixation of palatal fractures using three-dimensional plates

The maxilla is arguably the most anatomically intricate structure of the craniofacial skeleton, and the hard palate is an important bone that regulates the width and architecture of the face. The management of palatal fractures has long been a matter of debate, and varies with anatomical pattern and other injuries to the craniofacial skeleton. We have studied 18 palatal fractures during a five-year period that were treated using 3-dimensional rectangular plates placed across the palatal vault together with fixation of other fractures of the facial bones. Healing was satisfactory in all patients by 12 weeks, with no complications. We think that open reduction and internal fixation of palatal fractures with 3-dimensional plates offers adequate stability with minimal complications.     

The prosthetic rehabilitation of a panfacial fracture patient after reduction: A clinical report

Panfacial fractures involve trauma to the lower, middle, and upper facial bones and often require a team approach for management. Early and complete restoration of preinjury facial contours and function should be the goal of the oral and maxillofacial surgeon and the prosthodontist. When the intraoral landmarks are lost, overall facial anatomic landmarks can be used to restore the oral cavity. A patient with complex clinical panfacial fractures, including a vertically and horizontally malpositioned native alveolar bone and severe facial asymmetry, is presented. A functional and esthetic rehabilitation was successfully accomplished by using a partial removable dental prosthesis retained with telescopic crowns and magnetic attachments in the maxilla and osseointegrated implants to support a definitive dental prosthesis in the mandible.     

A new device for the orthodontic treatment of maxillary fractures

A new device for the treatment of maxillary fractures is described. Indications for its application are discussed. Experience gained in the treatment of 6 patients with fractures of the median segment of the face is presented.     

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提要：额窦位于颅面交界区,额窦骨折也处在多个临床学科的交叉点上。多年来,在额窦骨折治疗手段和治疗思路方面存在分歧和争议,主要集中在是继续保存额窦的解剖和功能,还是对其进行填塞或颅腔化处理。目前,对额窦骨折的治疗已经基本达成共识,即要依据额窦前、后壁以及鼻额管损伤程度来选择治疗方案。治疗方案主要有：保守治疗、骨折复位固定、额窦填塞以及额窦颅腔化。功能性内窥镜外科使得最大限度地保存额窦解剖和功能成为可能。本文从额窦骨折的解剖基础、临床表现及合并损伤、分类、影像学诊断、治疗、并发症、内窥镜技术的应用等方面加以综述,力图全面反映额窦骨折及其治疗的现状。     

Management of pediatric mandible fractures

The pediatric mandible fracture is a rare occurrence when compared with the number of mandible fractures that occur within the adult population. Although the clinician who manages facial fractures may never encounter a pediatric mandible fracture, it is a unique injury that warrants a comprehensive discussion. Because of the unique anatomy, dentition, and growth of the pediatric patient, the management of a pediatric mandible fracture requires true diligence with a variance in treatment ranging from soft diet to open reduction and internal fixation. In addition to the variability in treatment, any trauma to the face of a child requires additional management factors including child abuse issues and long-term sequelae involving skeletal growth, which may affect facial symmetry and occlusion. The following is a review of the incidence, relevant anatomy, clinical and radiographic examination, and treatment modalities for specific fracture types of the pediatric mandible based on the clinical experience at the University of Miami/Jackson Memorial Hospital Oral and Maxillofacial Surgery program. In addition, a review of the literature regarding the management of the pediatric mandible fracture was performed to offer a more comprehensive overview of this unique subset of facial fractures.