Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible

Patterns of Craniomaxillofacial Trauma at an Urban Level I Trauma Center

Background

There is a paucity in the literature concerning craniomaxillofacial trauma (CMF) in the USA. Better recognition of these fracture patterns and their management clarifies how to best evaluate and treat them.

Methods

A retrospective chart review was conducted of CMF trauma patients who required surgical intervention at a level I trauma center between 2015 and 2018. Descriptive statistics and univariate and bivariate analyses were conducted (α = 0.05).

Results

A total of 1001 patients were included. Most patients were Black (n = 665; 66%) and/or male individuals (n = 813; 57%) with an average age of 37 years (range 15 -110). The most common etiologies were assault (n = 471; 44%), motor vehicle collision (n = 238; 22%), and fall (n = 117; 11%). The mechanism of injury was a determinant of fracture type (P = 0.045). The most common CMF injuries were mandibular fracture (n = 953; 95%), maxillary fracture (n = 815; 81%), and orbital fracture (n = 206; 21%). Male sex predicted panfacial fractures (P = 0.045). Black patients experienced more severe CMF trauma compared with other races (P < 0.001). ORIF was the most common treatment for mandibular (n = 481; 73%) and maxillary (n = 62; 66%) fractures.

Conclusions

Etiology and patterns of CMF trauma differ globally, with assault and motor vehicle collisions being the leading causative factors in our patient population. Patient demographics are relatively consistent worldwide, with most injuries occurring in 30- to 40-year-old men. This study offers insight into at-risk populations and guidance on their management.

The Role of Imaging in Mandibular Reconstruction with Microvascular Surgery

Imaging plays a critical role in the diagnosis, staging, and management of segmental mandibular defects. Imaging allows mandibular defects to be classified which aids in microvascular free flap reconstruction. This review serves to complement the surgeon's clinical experience with image-based examples of mandibular pathology, defect classification systems, reconstruction options, treatment complications, and Virtual Surgical Planning.

Evidence-Based Medicine for Ballistic Maxillofacial Trauma

Ballistic trauma is a serious health issue with significant costs to physical, psychosocial, economic, and societal well-being. It may be caused from firearms, explosive devices, or any other projectile forces, and is characterized by severe tissue loss and evolving tissue devitalization. This review covers mechanism, diagnosis, and management of ballistic maxillofacial trauma, specifically. Initial evaluation includes stabilization of airway, bleeding, and circulation, followed by assessment of other injuries. The overall degree of tissue damage is determined by intrinsic patient factors and extrinsic projectile factors. Management of ballistic injuries has shifted toward advocation for early operative repair with the advent of antibiotics and advanced techniques in maxillofacial reconstruction. Appropriate timing and method of reconstruction should be carefully selected on a case-by-case basis. While ballistic trauma research is limited to studies biased by institutional practices, areas for further study identified from current literature include guidelines directing timing of reconstructive surgery; thresholds for free tissue transfer; handling of retained projectiles; incidence of surgical complications; and clinical outcomes for computer-aided surgical repair of these highly destructive injuries.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

Study Design

Retrospective case series; systematic review.

Objective

It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion.

Methods

A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis.

Results

Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline.

Conclusions

Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Conferred with a new life: A case report of management of a severe midface trauma and subsequent oral rehabilitation

Maxillofacial traumas have been associated with 14%-17% of all facial injuries. The most common etiology of mid-facial traumas is motor vehicle accidents followed by interpersonal assaults. The devastating nature of maxillofacial defects makes reconstruction of the midface challenging, due to multiple required surgeries and extensive rehabilitation phase. The midface has been defined as the area between the zygomaticofrontal sutures and the maxillary occlusal plane. Midface traumas are significantly more challenging to manage compared to isolated facial since there is limited intact and unharmed framework to guide with anatomic reductions. Therefore, the appropriate surgical approach to a maxillofacial trauma must follow a systematic scheme. Besides, one of the main consequences of maxillofacial traumas is destruction of the teeth and teeth bearing alveolar bone. Oral rehabilitation utilizing dental implants of these patients must be considered to provide the higher quality of life. Here, we report the management and further oral rehabilitation of a case suffering severe midface trauma following a motor vehicle accident where the patient was hit by a lorry.

Penetrating Midface Trauma: A Case Report, Review of the Literature, and a Diagnostic and Management Protocol

PURPOSE

Penetrating facial trauma is an uncommon injury, but patients who present with these dramatic situations require special consideration. We describe the case of a young man who had been shot with an arrow that deeply penetrated his midface as well as report the results of a literature review of penetrating midface injuries. The information gathered was used to create a diagnostic protocol for patients who sustain such injuries.

METHODS

A PubMed search up to October 2019 using several key phrases was performed, and 623 unique articles were evaluated. Excluding firearm injuries to the midface, there were 57 unique cases that involved penetrating midface injuries. Clinical and imaging data were compiled and evaluated with descriptive statistical analysis.

RESULTS

The average patient age was 27 years, with a male predilection. The most common reported etiology was accidental trauma (54%), and a knife was the most common weapon of injury (30%). The most common (32%) specific location of trauma was within the orbital region, including the canthus or the eyelid. In all cases where the patient had not died immediately, surgery was used to remove the penetrating object. We found that computed tomography was the most commonly obtained imaging study (39% of cases). Radiographs were the sole imaging in 28% of the cases, with angiography (16%) and magnetic resonance imaging (10%) used less frequently in management. In 28% of the cases, deep structures, such as the carotid artery, sphenoid sinus, or skull base, were involved in the injury. In 25% of the cases, there was injury to the central nervous system. Death occurred in 8.8% of the cases. Postoperative complications occurred in at least 21% of the cases. Statistical analysis also revealed a significant correlation between antibiotic use and full recovery. Penetration of the object posterior to the maxillary sinus was correlated with incomplete recovery or death.

CONCLUSIONS

Based on all case reports collected, a Dartmouth Penetrating Midface Protocol was developed to aid the practitioner who may happen to be responsible for these dramatic life-threatening injuries. The Dartmouth Penetrating Midface Protocol is based on the type of imaging available at the treating facility, the neurologic and hemodynamic stability of the patient, and the depth of penetration beyond the posterior wall of the maxillary sinus.

Maxillofacial gunshot injures and their therapeutic challenges: Case series

Maxillofacial gunshot injuries require proficiency to determine a suitable treatment plan and surgical intervention. In this paper, present 4 gunshot cases. Treatment in these patients is very challenging. Moreover, post-treatment infections are a serious problem in such cases. Thus, step-by-step surgery is essential to obtain a better result in these patients.

Reconstruction of segmental mandibular defects: Current procedures and perspectives

Background

The reconstruction of segmental mandibular defects remains a challenge for the reconstructive surgeon, from both a functional and an esthetic point of view.

Methods

This clinical review examines the different techniques currently in use for mandibular reconstruction as related to a range of etiologies, including the different bone donor sites, the alternatives to free flaps (FFs), as well as the contribution of computer‐assisted surgery. Recent progress and the perspectives in bone tissue engineering (BTE) are also discussed.

Results

Osseous FF allows reliable and satisfying outcomes. However, locoregional flap, distraction osteogenesis, or even induced membrane techniques are other potential options in less favorable cases. Obtaining an engineered bone with satisfactory mechanical properties and sufficient vascular supply requires further investigations.

Conclusions

Osseous FF procedure remains the gold standard for segmental mandible reconstruction. BTE strategies offer promising alternatives.

Surgical Management of Gunshot Injury to the Temporomandibular Joint

One of the indications of the surgical approach of the temporomandibular joint is the presence of foreign body in its interior. However, joint handling offers risks, especially bleeding. In these cases, angiography and embolization of the arteries involved with the projectile play an important role in the prevention of complications. In this report, the authors describe a case of a 23-year-old male victim of firearm attack with comminuted fracture of the right mandibular condyle. The patient underwent angiography and prophylactic embolization of the arteries adjacent to the foreign body. A surgical procedure was performed to remove the projectile and bone fragments with the aid of the X-ray image intensifier, which resulted in the restoration of mandibular function, absence of joint pain, and satisfactory dental occlusion. This case shows the importance of auxiliary imaging methods for performing a safe surgical procedure for removal of ballistic and bony fragments from the interior of the temporomandibular joint.