Current concepts in management of facial trauma

The Orthodontist's Role in Post-Battlefield Craniomaxillofacial Trauma Reconstruction

INTRODUCTION

In modern conflicts, deployed members are more vulnerable to craniomaxillofacial (CMF) injury than in previous conflicts. Patients presenting with CMF trauma are susceptible to post-trauma dental malocclusion and may require lengthy rehabilitation to achieve pre-injury function. This study surveyed military health care professionals who are potential contributors to CMF trauma rehabilitation teams to evaluate the orthodontist's inclusion in treating to the final outcome.

METHODS

Following approval from the Defense Health Agency Information Management Collections Office (Control Number: 9-DHA-1031-E) and the Air Force 59th Medical Wing Institutional Review Board (Reference Number: FWH20210061E), a survey study was conducted from April 2021 to July 2021. Volunteer participants were recruited from orthodontists, oral maxillofacial surgeons, medical specialists, and other dental specialists who have worked in military healthcare. Respondents reported their current practice treating CMF trauma, self-evaluated their knowledge of different aspects of the process, and submitted their perceptions on system and patient-limiting factors which affect outcomes. Descriptive statistics were conducted for ordinal data and chi-square tests for categorical data. Kruskal-Wallis analyses of variance compared cohorts with further Mann-Whitney U tests to distinguish the difference in cohorts.

RESULTS

Valid responses were collected from 171 participants. The responses were mostly from active duty military (93%) and well distributed among orthodontists, oral maxillofacial surgeons, other dental specialists, and medical specialists. When reporting current CMF trauma treatment practices, the majority of dental specialists stated they most commonly participate in a multidisciplinary team that addresses any CMF trauma case (68.4%) whereas medical specialists most commonly act as solo independent provider practice (53.6%). Dental specialists reported follow-up with post-trauma patients greater than 1 year and medical specialists reported the shortest post-trauma follow-up time with a median of 0 to 3 months. The majority of participants selected at least one system factor limiting CMF trauma care (78.7%) and at least one patient factor limiting CMF trauma care (86.3%). When asked about orthodontic participation in multidisciplinary teams, the responses showed a great range with orthodontists never included in CMF trauma care 23.1% of the time and always consulted regarding trauma cases 10.7% of the time. Other survey data collected allows the investigators to draw conclusions regarding specific limitations to treatment and recommendations for improvement, along with qualitative responses from survey participants.

CONCLUSIONS

Orthodontics, while available in the military, is underutilized in treating post-warfare or other CMF trauma. There are both system- and patient-limiting factors in the treatment of battlefield and non-battlefield CMF trauma. In addition, there are limitations to the inclusion of orthodontists in CMF trauma care which include the physical distance from primary treating specialists and the absence of standard referral protocols. Oral maxillofacial surgeons reported the highest understanding of the military orthodontist's contribution to a CMF trauma treatment team and medical specialists reported the lowest understanding. Advanced technology tools could help improve outcomes and multidisciplinary interactions. Further research is needed to study the complete CMF trauma rehabilitation process in military treatment facilities, evaluate the efficiency of cross-specialty referrals, and highlight best practices and protocols of functioning multidisciplinary teams.

Common dental and orofacial trauma: evaluation and management

This article reviews common dental and orofacial traumatic injuries, and provides a broad overview and general principles of the diagnosis and management of common dental and orofacial injuries. Such knowledge will aid the physician in recognition and assessment of injury, proper treatment, and appropriate referral to the specialist. Although many of these injuries warrant appropriate consultation, a sound understanding of assessment and treatment protocol is important.

Facial gunshot wounds: a 4-year experience

PURPOSE

Facial gunshot wounds can result in devastating functional and aesthetic consequences for patients. In an attempt to evaluate the management and outcome in these patients, a 4-year retrospective review was undertaken of all patients presenting with facial gunshot wounds at a level I trauma center.

PATIENTS AND METHODS

A total of 121 patients were identified. Medical documentation could be obtained on 84 of those patients. The patients' maxillofacial injuries were treated by the 3 participating services: plastic surgery, oral and maxillofacial surgery, and otorhinolaryngology. The patients ranged in age from 6 to 64 years, with a mean age of 27 years.

RESULTS

The gunshot wounds were single in 64% of the cases and multiple in 36% of the cases. Overall mortality in the series was 11%. Sixty-seven percent (56/84) of the patients suffered an injury to the underlying craniofacial skeleton. Seventy-five percent of these patients required surgical intervention. Twenty-one percent of the patients (16/75) required tracheostomy emergently for management of the airway. Eighteen percent (15/84) of these patients had an intracranial injury, with 50% of these patients requiring surgery. Fourteen percent of the patients in the series (12/84) had great vessel injuries diagnosed at the time of angiography, with 50% of these patients requiring surgery for treatment.

CONCLUSION

Contrary to much of the published literature, most patients in this series required surgical intervention for treatment of their facial gunshot wounds. Reconstructive procedures were performed early in the patient's course and, when possible, addressed both the soft tissue and underlying bony injury in a minimum number of stages.