Craniomaxillofacial Trauma Research Articles

Characterizing Craniomaxillofacial Injuries in American Professional Sports Leagues

The purpose of this study was to characterize the types of craniomaxillofacial (CMF) injuries that occur in professional sports leagues and the associated recovery times. A retrospective cohort study was designed and implemented using the Pro Sports Transaction Archive. The database was queried for all registered CMF injuries in the 4 main men's major professional sports leagues in the United States from 2013 to 2018. The sport, injury location, and season were the predictor variables, and the frequency and length of time on the injured list were the outcome variables. Descriptive statistics were computed, and Fisher's exact tests were used to determine the association between the predictor and outcome variables. Analysis of variance was used to compare the injury frequency and duration. Of the 198 injuries that met the inclusion criteria, 60 were from Major League Baseball (MLB) (30%), 49 from the National Basketball Association (25%), 8 from the National Football League (4%), and 81 from the National Hockey League (NHL) (41%). Injuries to the midface were most common (mean, 25.2±3.6 injuries per season; P<.001) compared with the upper face (mean, 6.0±2.0 injuries per season) and lower face (mean, 8.4±2.3 injuries per season). The mean time on the injured list after CMF trauma was 8.4±10.4days, with MLB injuries requiring the shortest duration (mean, 3.9±6.6days; P=.001). A significant association was found between the injury location and sport (P<.001). However, no statistically significant difference was found in the number of injuries per season from 2013 to 2018 for each league (P=.818). Midface trauma was significantly more common than upper or lower face trauma in professional sports leagues during the past 5 seasons. The NHL had the greatest injury rate, even after adjustment for games played.

The Comprehensive AO CMF Classification System for Mandibular Fractures: A Multicenter Validation Study.

The AO CMF has recently launched the first comprehensive classification system for craniomaxillofacial (CMF) fractures. The AO CMF classification system uses a hierarchical framework with three levels of growing complexity (levels 1, 2, and 3). Level 1 of the system identifies the presence of fractures in four anatomic areas (mandible, midface, skull base, and cranial vault). Level 2 variables describe the location of the fractures within those defined areas. Level 3 variables describe details of fracture morphology such as fragmentation, displacement, and dislocation. This multiplanar radiographic image-based AO CMF trauma classification system is constantly evolving and beginning to enter worldwide application. A validation of the system is mandatory prior to a reliable communication and data processing in clinical and research environments. This interobserver reliability and accuracy study is aiming to validate the three current modules of the AO CMF classification system for mandible trauma in adults. To assess the performance of the system at the different precision levels, it focuses on the fracture location within the mandibular regions and condylar process subregions as core components giving only secondary attention to morphologic variables. A total of 15 subjects individually assigned the location and features of mandibular fractures in 200 CT scans using the AO CMF classification system. The results of these ratings were then statistically evaluated for interobserver reliability by Fleiss' kappa and accuracy by percentage agreement with an experienced reference assessor. The scores were used to determine if the variables of levels 2 and 3 were appropriate tools for valid classification. Interobserver reliability and accuracy were compared by hierarchy of variables (level 2 vs. level 3), by anatomical region and subregion, and by assessor experience level using Kruskal-Wallis and Wilcoxon's rank-sum tests. The AO CMF classification system was determined to be reliable and accurate for classifying mandibular fractures for most levels 2 and 3 variables. Level 2 variables had significantly higher interobserver reliability than level 3 variables (median kappa: 0.69 vs. 0.59, p < 0.001) as well as higher accuracy (median agreement: 94 vs. 91%, p < 0.001). Accuracy was adequate for most variables, but lower reliability was observed for condylar head fractures, fragmentation of condylar neck fractures, displacement types and direction of the condylar process overall, as well as the condylar neck and base fractures. Assessors with more clinical experience demonstrated higher reliability (median kappa high experience 0.66 vs. medium 0.59 vs. low 0.48, p < 0.001). Assessors with experience using the classification software also had higher reliability than their less experienced counterparts (median kappa: 0.76 vs. 0.57, p < 0.001). At present, the AO CMF classification system for mandibular fractures is suited for both clinical and research settings for level 2 variables. Accuracy and reliability decrease for level 3 variables specifically concerning fractures and displacement of condylar process fractures. This will require further investigation into why these fractures were characterized unreliably, which would guide modifications of the system and future instructions for its usage.

Management of Complex Mandible Fractures.

Mandible fractures represent a common sequela of craniomaxillofacial trauma encountered by reconstructive surgeons. Management of complex mandibular fractures, and reestablishment of the occlusal relationship, represents a challenging reconstructive endeavor for even the most skilled surgeon. In this article, the authors review the treatment options for particularly complex presentations of this injury pattern.

Management of Orbital Floor Fractures.

Fractures of the orbital floor represent a common yet difficult to manage sequelae of craniomaxillofacial trauma. Repair of these injuries should be carried out with the goal of restoring normal orbital volume, facial contour, and ocular motility. Precise surgical repair is imperative to reduce the risk of long-term debilitating morbidity. This article aims to review concepts on the management of orbital floor fractures in the hope of further elucidating perioperative evaluation and decision-making regarding operative intervention.

Oral and cranio-maxillofacial trauma in children and adolescents in an emergency setting at a Brazilian hospital.

Very few studies have been performed to evaluate cranio-maxillofacial trauma diagnosed in hospitals in children and adolescents. The aim of this study was to perform an analysis of oral and cranio-maxillofacial trauma in the aforementioned population. A hospital-based retrospective study, which reviewed 1438 patient records, was conducted at the "Teresina Emergency Hospital", Brazil. Data regarding demographics, day of the week on which trauma occurred, type of injury, etiology, anatomic trauma site, time of hospital admission, and associated comorbidities (or injuries) were collected. There were 1092 (75.9%) males and 346 (24.1%) females. The largest group was adolescents aged between 13 and 18years (956, 66.5%). The majority lived in urban areas (69%). Trauma occurred most frequently during the week. The most prevalent etiology was road traffic accidents involving motorcycles (771, 53.6%) causing facial and skull fractures (598, 41%). The most prevalent soft tissue lesions were facial abrasions (49%), followed by injuries to the cheek (16.7%). Comorbidities associated with craniofacial trauma were present in 82%, with complications from traumatic brain injuries being the most prevalent (65.6%) Dental trauma was recorded in only 81 cases (5.6%). Male adolescents living in urban areas were most affected by craniofacial trauma. The most common cause was road traffic accidents involving motorcycles, resulting in facial and skull fractures. Complications from traumatic brain injuries were the most common associated injuries.

Absorbable Fixation Devices for Pediatric Craniomaxillofacial Trauma: A Systematic Review of the Literature.

The purpose of this study was to investigate surgical outcomes with the use of resorbable plating systems for the repair of craniomaxillofacial trauma in the pediatric population. A systematic review of the literature was performed. A descriptive analysis, operative technical data, outcomes, and postoperative complications with the use of absorbable plating systems for craniomaxillofacial trauma were included. The systematic literature review identified 1264 abstracts, of which only 19 met inclusion criteria. From these 19 studies, 312 clinical cases with 443 facial fractures that were treated with absorbable fixation systems were extracted for analysis. The review identified only level III/IV (n = 17) and level V (n = 2) studies. Minor and major complications were rare, occurring in 5.45 percent (n = 17) and 3.21 percent (n = 10) of cases, respectively. The most common complications were surgical-site infections (n = 4) and plate extrusion (n = 4). This report is, to the authors' knowledge, one of the first comprehensive reports on the use of absorbable plating systems for pediatric craniomaxillofacial trauma. Their analysis suggests that the use of absorbable fixation devices for pediatric craniomaxillofacial trauma is relatively safe, with a low-risk profile. Outcome studies with longer follow-up periods specifically investigating facial growth, reoperation rates, standardized surgical outcome metrics, and cost are necessary to effectively compare these fixation devices to titanium alternatives for craniomaxillofacial trauma.

Update on the management of craniomaxillofacial trauma in low-resource settings.

Craniomaxillofacial (CMF) trauma is a common cause of global morbidity and mortality. Although in high resource settings the management of CMF trauma has improved substantially over the past several decades with internal rigid fixation technology; these advancements have remained economically unviable and have not yet reached low and middle-income countries (LMICs) en masse. The purpose of this review is to discuss the current management of CMF injuries in low-resource settings. Trauma injuries remain a global epidemic with head and neck injuries among the most common. CMF trauma injuries largely occur in LMICs, with motor vehicle trauma being a common cause. Patients present in a delayed fashion which increases complications. Diagnostic methods are often limited to plain radiographs as computed tomography is not always available. In low-resource settings, CMF trauma continues to be treated primarily by closed reduction, maxillomandibular fixation, and transosseous wiring, yielding acceptable results through affordable methods. With the advent of less expensive plating systems, internal fixation with plates and screws are gradually finding their place in the management of facial trauma in low-resource settings. A shortage of CMF surgeons in LMICs is a recognized problem and is being addressed by targeted curricula. CMF trauma is a major cause of morbidity and mortality globally that remains poorly addressed. Currently, conventional methods of treating CMF trauma in low-resource settings have evolved to meet resource constraints. The education of CMF surgeons remains a key leverage point in improving CMF trauma care globally.

S5B-02 SESSION 5B: TRAUMA FACE THE FREQUENCY OF CERVICAL SPINE INJURIES IN PEDIATRIC CRANIOMAXILLOFACIAL TRAUMA PATIENTS – THE 20-YEAR EXPERIENCE AT THE JOHNS HOPKINS HOSPITAL

Introduction: Craniomaxillofacial (CMF) fractures are accepted as injuries at high risk for concomitant cervical spine or spinal cord injuries. However, there is a paucity of studies investigating the relationship between CMF fractures and cervical spine injuries (CSI) in the pediatric population. The purpose of this study was to investigate the frequency of CSI after CMF trauma at a level-1, pediatric, tertiary, trauma center. Methods: A retrospective cohort review of all pediatric patients (ages 0–15) who presented to the Johns Hopkins Hospital from 1990–2010 with CMF fractures were examined for concurrent CSI injuries. Patient charts were reviewed for mechanism of injury, dentition stage, type of CSI, location of CMF fracture patterns, and overall outcome. Results: A total of 2966 pediatric patients (ages 0–15) were identified from 1990 to 2010 to have suffered CMF fractures, with an average age of 7 ± 4.73 years, and 1897 (64.0%) male. Of these patients, only five children were found to have concomitant CSIs (0.169% frequency). The frequency of CSI in CMF fracture patients with deciduous, mixed, and permanent dentition was 0%, 0.307%, and 0.441%, respectively. Of the five identified cases, four had concomitant middle-third facial skeleton fractures, four had concomitant upper-thirds cranial skeletal fracture, and two had concomitant lower-thirds cranial skeletal fractures. Conclusion: The frequency of CSIs in children with CMF fractures is significantly lower (0.169%) than the reported ranges in adults (3.69–24%). No child of deciduous dentition was found to have a CSI. The lack of CSI in deciduous CMF fracture patients could be explained by the anatomic differences between pediatric and adult cervical spines. The higher frequency of CSI in CMF trauma patients of mixed or permanent dentition also suggests that the use of the NEXUS and CCS may be efficacious in this population. However, future prospective studies will be required to develop pediatric-specific risk-stratification tools for this unique population. Until such studies are performed, we recommend that all high-risk CMF trauma patients be assessed clinically and stabilized with a cervical collar. If indicated, plain radiography with two views should be obtained. If plain radiography is inconclusive and there remains an increased index of suspicion, a CT scan or a T2 (STIR) MRI should be utilized to rule out bony or ligamentous injuries

Craniomaxillofacial Trauma Experience in Otolaryngology Residency: A National Survey of Program Directors.

This article aimed to assess the depth and volume of craniomaxillofacial (CMF) trauma exposure and education in otolaryngology residency training in the United States. This is a cross-sectional survey. A 15-question web-based survey was distributed to program directors of 106 Accreditation Council for Graduate Medical Education (ACGME)-approved otolaryngology residency programs to inquire about program size and demographics, trauma coverage, case volume, and education. Responses were collected anonymously. A total of 77 responses were received, representing 73% of residency programs. Seventy-five programs (97%) reported that their residents rotated at a level 1 trauma center, and 72 (94%) covered CMF trauma. Sixty-one programs (79%) included pediatric CMF trauma. The majority of programs (76%) allocated less than 10% of residency-dedicated didactic lecture time to CMF trauma. Residents in all programs typically logged at least 11 to 20 cases before graduation with 24% of programs averaging more than 50 cases per resident. Ninety percent of respondents described the training as "somewhat" to "very adequate." CMF coverage by the otolaryngology department, number of cases, and dedicated didactic lecture time to CMF trauma were significant factors on the perception of adequate training. The majority of program directors felt that the training in CMF trauma was adequate. Reasons for this may include that most residents rotate at level 1 trauma centers, have exposure to pediatric trauma, encounter an adequate volume of cases, and have dedicated didactic time to CMF education.

Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma

In pediatric patients with craniomaxillofacial (CMF) trauma, evaluation for cervical spine injury (CSI) is critical, but there are no studies investigating CSI in this unique population. The aim of this study was to measure the frequency of CSI in the pediatric CMF fracture population. A retrospective cohort study of all pediatric patients who presented to the Johns Hopkins Hospital Emergency Department (Baltimore, MD) with CMF fractures were examined for concurrent CSIs. Patient charts were reviewed for mechanism of injury, type and level of CSI, type and location of CMF fracture patterns, and overall outcome. Data were analyzed for correlation and statistical relevance. A total of 2,966 pediatric patients (1,897 boys [64.0%]; age range, 0 to 15yr; average age, 7±4.73yr) were identified from 1990 to 2010 to have CMF fractures. Of these patients, only 5 children were found to have concomitant CSIs (frequency, 0.169%). The frequency of CSI in patients with CMF fracture and deciduous, mixed, and permanent dentition was 0, 0.307, and 0.441%, respectively. Of the 5 identified cases, 4 had concomitant middle-third facial skeletal fracture, 4 had concomitant upper-third cranial skeletal fracture, and 2 had concomitant lower-third cranial skeletal fracture. CSIs in pediatric patients with CMF fracture are rare (frequency, 0.169%); this is considerably lower than the reported ranges in adults (3.69 to 24%). No child with deciduous dentition was found to have a CSI. The lack of CSI in deciduous patients with CMF fracture could be explained by the anatomic differences between pediatric and adult cervical spines and supports conservative imaging for children in this age group (level of evidence, III).

Delayed contralateral traumatic carotid cavernous fistula after craniomaxillofacial fractures.

A carotid-cavernous sinus fistula is a rare condition in which an abnormal communication exists between the internal or external carotid artery and the cavernous sinus. It typically occurs within a few weeks after craniomaxillofacial trauma. In most cases, the carotid-cavernous sinus fistula occurs on the same side as the craniomaxillofacial fracture. We report a case of delayed carotidcavernous sinus fistula that developed symptoms 7 months after the craniomaxillofacial fracture. The fistula developed on the side opposite to that of the craniomaxillofacial fracture. Based on our experience with this case, we recommend a long follow-up period of 7–8 months after the occurrence of a craniomaxillofacial fracture. We also recommend that the follow-up should include consideration of the side contralateral to the injury.

Epidemiological Features of Patients with Craniomaxillofacial Fractures: A Single Centre Study

Purpose: It has been shown that cranial injuries associated with facial fractures may cause a great risk of mortality and neurological morbidity, which mainly occurs in young adults. Various studies have been carried out in various countries to study the epidemiology of the cranio maxillofacial injuries but the studies from Egypt are few. The aim of this study was therefore to assess the prevelance, etiology, type of injury, and site of fractures among patient attending Assiut University Hospitals. Material and Methods: Retrospective hospital study was carried out at Trauma unit, Assiut University Hospitals (Single Tertiary Hospital) between January 2010 and December 2017. Radiographs and hospital data of 1745 patients with craniomaxillofacial trauma were gathered and analyzed. The identified fractures, such as, age, gender, etiology of injury, and anatomical sites of fractures were classified as: frontal/skull base, naso-orbital, maxilla, zygoma, and mandible. According to GCS, patients were classified into 3 grades: mild, moderate and severe. Gathered data was coded and entered into a computer and analyzed using SPSS version 22. Result: Overall prevalence of cranio maxillofacial injuries was 3%. Age ranged from 1 - 90 with mean ± SD 25.75 ± 15.5. The greatest number of the patients had 18 to 40 years old (48.4%) and most of them were male (M/F ratio was 7:1). The most prevalent causes of the trauma in this study were the road traffic accidents (67.7%) and accidental fall (15%), respectively. Firearm injuries accounted for fractures in 86 patients (4.9%). The most common bone fracture among the patients was the mandibular bone (47.7%). 837 patients (48%) required surgical intervention. Conclusions: This retrospective population study demonstrates an insight into the demographics and fracture patterns in craniomaxillofacial trauma patients. The most common etiology of craniomaxillofacial injury was road traffic accidents followed by falls and assaults, suggesting that interventions addressing the prevention of this mechanism, and treatment of the associated injury patterns, have not been sufficient and require to be revised. The majority of victims were young adult males between the ages of 18 to 40 years. The mandibular bone and maxilla were the most common sites of fracture.

Estimating Reference Bony Shape Model for Personalized Surgical Reconstruction of Posttraumatic Facial Defects.

In this paper, we introduce a method for estimating patient-specific reference bony shape models for planning of reconstructive surgery for patients with acquired craniomaxillofacial (CMF) trauma. We propose an automatic bony shape estimation framework using pre-traumatic portrait photographs and post-traumatic head computed tomography (CT) scans. A 3D facial surface is first reconstructed from the patient's pre-traumatic photographs. An initial estimation of the patient's normal bony shape is then obtained with the reconstructed facial surface via sparse representation using a dictionary of paired facial and bony surfaces of normal subjects. We further refine the bony shape model by deforming the initial bony shape model to the post-traumatic 3D CT bony model, regularized by a statistical shape model built from a database of normal subjects. Experimental results show that our method is capable of effectively recovering the patient's normal facial bony shape in regions with defects, allowing CMF surgical planning to be performed precisely for a wider range of defects caused by trauma.

Relationship Between Nasal Fracture and Blowout Fracture: Can Nasal Fracture Be a Predictor of Blowout Fracture?

Nasal and blowout fractures are the most common injuries from craniomaxillofacial trauma. Nasal fractures are easily diagnosed by clinical signs, such as pain and crepitus. However, blowout fractures are frequently asymptomatic and are easy to miss without computed tomographic (CT) scanning. This study analyzed the relation between the 2 fracture types to determine whether nasal fracture could be used as a predictor of blowout fracture. CT scans of 1,368 patients who underwent reduction surgery for nasal fracture were retrospectively reviewed. The pattern of nasal fractures (n=1,368) was classified as frontal or lateral according to the direction of impact. Blowout fractures (n=297) were classified into 3 types according to the position of the fracture: medial, inferior, or inferomedial wall. After calculating the number of patients in each group, the relation between nasal and blowout fracture types was statistically analyzed. Of 305 patients with frontal-type nasal fractures, the incidence of medial, inferior, and inferomedial wall fracture was 26, 7, and 9, respectively. Of 1,063 patients with lateral-type nasal fractures, the incidence of medial, inferior, and inferomedial wall fracture was 118, 75, and 62, respectively. Medial wall fracture was most common in the 2 nasal fracture groups and showed a higher frequency in the lateral-type group. This study showed a strong relation between nasal fractures and medial wall blowout fractures. If nasal fracture is suspected, especially the lateral type, then thorough examination for medial wall blowout fracture, with a high index of suspicion, should be performed.

Mechanical Evaluation of Retinal Damage Associated With Blunt Craniomaxillofacial Trauma: A Simulation Analysis.

PurposeTo evaluate retinal damage as the result of craniomaxillofacial trauma and explain its pathogenic mechanism using finite element (FE) simulation.MethodsComputed tomography (CT) images of an adult man were obtained to construct a FE skull model. A FE skin model was built to cover the outer surface of the skull model. A previously validated FE right eye model was symmetrically copied to create a FE left eye model, and both eye models were assembled to the skull model. An orbital fat model was developed to fill the space between the eye models and the skull model. Simulations of a ball-shaped object striking the frontal bone, temporal bone, brow, and cheekbones were performed, and the resulting absorption of the impact energy, intraocular pressure (IOP), and strains on the macula and ora serrata were analyzed to evaluate retinal injuries.ResultsStrain was concentrated in the macular regions (0.18 in average) of both eyes when the frontal bone was struck. The peak strain on the macula of the struck-side eye was higher than that of the other eye (>100%) when the temporal bone was struck, whereas there was little difference (<10%) between the two eyes when the brow and cheekbones were struck. Correlation analysis showed that the retinal strain time histories were highly correlated with the IOP time histories (r > 0.8 and P = 0.000 in all simulation cases).ConclusionsThe risk of retinal damage is variable in craniomaxillofacial trauma depending on the struck region, and the damage is highly related to IOP variation caused by indirect blunt eye trauma.Translational RelevanceThis finite element eye model allows us to evaluate and understand the indirect ocular injury mechanisms in craniomaxillofacial trauma for better clinical diagnosis and treatment.

Backward Planning a Craniomaxillofacial Trauma Curriculum for the Surgical Workforce in Low-Resource Settings.

Trauma is a significant contributor to global disease, and low-income countries disproportionately shoulder this burden. Education and training are critical components in the effort to address the surgical workforce shortage. Educators can tailor training to a diverse background of health professionals in low-resource settings using competency-based curricula. We present a process for the development of a competency-based curriculum for low-resource settings in the context of craniomaxillofacial (CMF) trauma education. CMF trauma surgeons representing 7 low-, middle-, and high-income countries conducted a standardized educational curriculum development program. Patient problems related to facial injuries were identified and ranked from highest to lowest morbidity. Higher morbidity problems were categorized into 4 modules with agreed upon competencies. Methods of delivery (lectures, case discussions, and practical exercises) were selected to optimize learning of each competency. A facial injuries educational curriculum (1.5days event) was tailored to health professionals with diverse training backgrounds who care for CMF trauma patients in low-resource settings. A backward planned, competency-based curriculum was organized into four modules titled: acute (emergent), eye (periorbital injuries and sight preserving measures), mouth (dental injuries and fracture care), and soft tissue injury treatments. Four courses have been completed with pre- and post-course assessments completed. Surgeons and educators from a diverse geographic background found the backward planning curriculum development method effective in creating a competency-based facial injuries (trauma) course for health professionals in low-resource settings, where contextual aspects of shortages of surgical capacity, equipment, and emergency transportation must be considered.

How are we currently training and maintaining clinical readiness of US and UK military surgeons responsible for managing head, face and neck wounds on deployment?

IntroductionThe conflicts in Iraq and Afghanistan provided military surgeons from the USA and the UK with extensive experience into the management of injuries to the head, face and neck (HFN)...

Trend and Demographic Characteristics of Maxillofacial Fractures in Level I Trauma Center.

The aim of this study was to analyze the pattern and treatment of craniomaxillofacial injuries in the northern part of Israel, within a Jewish majority and large Arab minority population. A 5-year retrospective study evaluated patients treated for craniomaxillofacial fractures. Fracture cause, type, site, and patient demographics were evaluated. Patient age ranged from 1 to 94 years with an average age of 36.7 years; 52% of the victims were Jews and 48% Arabs. There was male predilection in both sectors (78.3% vs 21.7%). The main site of injury was the zygomatic bone (33.5%) followed by nasal bone, orbital, mandible, frontal sinus, and maxillary fractures. The main etiology of injuries was falls (45.4%) with significantly more falls reported by females (52.1% vs 43.2% in males). Motor vehicle accidents caused injuries more frequent in males. Arabs experienced CMF fractures at a younger age compared to Jews (27.8 and 44.8 average age, respectively). In the elderly, the trend reversed where Jews were more prone to craniomaxillofacial fractures. Compared to their weight in the population, the Arab sector experiences more craniomaxillofacial injuries. The Jewish elderly population tends to reside in nursing homes where they are more susceptible to accidental falls, whereas young Arab males are more exposed to motor vehicle accidents and interpersonal violence. Falls were the main cause of injuries particularly in women. This may reflect the women's fear of reporting domestic violence. We believe that increased government investments in infrastructures and education will lower the incidence of craniomaxillofacial trauma and balance the gap between both sectors and sexes.

Landmark-Independent Method to Determine Midsagittal Plane and Its Clinical Application in Craniomaxillofacial Trauma

The purpose of this study was to explore new landmark-independent methods suitable for determining the midsagittal plane (MSP) in patients with craniomaxillofacial trauma and its clinical application. Preoperative spiral computed tomography data of 25 patients with craniomaxillofacial trauma were imported into Mimics software (Materialise, Leuven, Belgium) to reconstruct 3-dimensional skull models.In the experimental group, the MSP was determined by different landmarks that were clear, were scattered, and did not have displacement according to the types of fractures. In the control group, the MSP was determined by a traditional landmark-dependent method based on the nasion, posterior nasal spine, and anterior nasal spine. After virtual fracture reduction, facial symmetry was determined to verify the reliability of both the landmark-dependent and landmark-independent methods. By use of the landmark-independent method proposed in this study, the minimal, maximal, andaverage registered distance between the skull model after reduction and the mirror skull model was 0.5531, 1.2065, and 0.8287mm, respectively. By use of the traditional landmark-dependent method, the minimal, maximal, and average registered distance between the skull model after reduction and the mirror skull model was 0.7914, 1.9415, and 1.2250mm, respectively. When an average distance of less than 1.5mm between the 2 registered models was set as the criterion for qualified fracture reduction, all 25 cases in the experimental group had qualified reduction whereas 9 cases in the control group had unqualified reduction (P<.05). Compared with the traditional landmark-dependent system, the landmark-independent method is more reliable in determining the MSP in patients with craniomaxillofacial trauma. Selection of different landmarks in different types of fractures makes it more precise to reconstruct the MSP and can guide virtual reduction of fractures more effectively, which lays the foundation for subsequent surgical navigation and guide-plate printing. The method is easy to perform and appropriate for digital evaluation of surgery.

Facial Trauma Care in the Austere Environment.

As the United States continues to increase its use of Special Operations Forces worldwide, treatment of craniomaxillofacial (CMF) trauma must be adapted to meet the needs of the warfighter. The remoteness of Special Operations can result in potentially longer times until definitive treatment may be reached. A significant portion of Servicemembers incur injury to the CMF region (42%). Severe CMF trauma can result in substantial hemorrhage and airway compromise. These can be immediately life threatening and must be addressed expeditiously. Numerous devices and techniques for airway management have been made available to the forward provider. A thorough review of nonsurgical and surgical airway management of the patient with facial injury for the forward provider and providers at receiving facilities is provided in this article. Techniques to address flail segments of the facial skeleton are critical in minimizing airway compromise in these patients. There are many methods to control hemorrhage from the head and neck region. Hemorrhage control is critical to ensure survival in the austere environment and allow for transport to a definitive care facility. Associated injuries to the cervical spine, globe, skull base, carotid artery, and brain must be carefully evaluated and addressed in these patients. Management of vision- threatening orbital compartment syndrome is critical in patients with CMF injuries. Because the head and neck region remains relatively vulnerable in the warfighter, combat CMF trauma will continue to occur. Forward providers will benefit from a review of the acute treatment of CMF traumatic injury. Properly triaging and treating facial injuries is necessary to afford the best chance of survival for patients with a devastating combat CMF injury.