Management Of Facial Fractures Research Articles

F057 Nationwide network of teleaudiology in postoperative care over implanted patients

In many ways, oral surgical procedures for children are similar to and possibly easier than those performed for adults. There are some important differences as well. The purpose of this section is to present basic techniques and surgical principles needed to perform oral surgical procedures safely and competently on children and adolescents. This section discusses the extraction of teeth, minor soft tissue procedures (e.g., biopsies and frenectomies), odontogenic infections, and the recognition and initial management of facial injuries and fractures. This chapter presents an overview of the principles of successful oral surgical procedures in children.

Acquired Entropion Associated With the Transconjunctival Incision for Facial Fracture Management

Transconjunctival incisions are used in cases of orbitozygomatic trauma and elective lower eyelid blepharoplasty. Although this approach has reduced the rates of ectropion, there is a rare but reported incidence of entropion. We review our experience with craniofacial trauma between 1998 and 2008 and our use of the transconjunctival, subtarsal, and subciliary approaches. We describe 2 patients where entropion occurred after a transconjunctival approach for repair of orbital and zygomatic fractures and review the literature. With the increasing popularity of this incision in reconstructive and cosmetic plastic surgery, a complete understanding of orbital anatomy and associated treatment options for entropion is necessary.

Contemporary management of pediatric facial trauma

Facial fracture management is often complex and demanding, particularly within the pediatric population. Although facial fractures in this group are uncommon relative to their adult counterparts, a thorough understanding of issues relevant to pediatric facial fracture management is critical to optimal long-term success. Children are not 'small adults', and the management of facial fractures in this population is unique. Injuries tend to be less severe, and can often be managed with soft diet and restriction of activity. Maxillomandibular fixation should be used only when indicated, as it can result in temporomandibular joint (TMJ) disturbances; to minimize this risk, it should be in place no longer than 7 days. Open reduction and internal fixation is indicated in severe injuries, and the surgeon must be cognizant of developing teeth. Small plates and screws are useful in this patient population. In this review of modern management of the pediatric facial trauma patient, several issues germane to pediatric facial fractures are discussed. Thorough ophthalmologic and dental/occlusive examinations must be undertaken. Conservative management is optimal for many injuries, as the pediatric fracture is typically not as severe as those seen in the adult facial skeleton. When wiring the jaw to allow for noninvasive fixation, treatment time must be short in order to avoid TMJ ankylosis. Rigid fixation is indicated in the rare comminuted, displaced fracture; when employed, the surgeon must use small plates and screws, and avoid injury to developing teeth. These are challenging cases, but with appropriate knowledge and understanding, they can be appropriately managed.

Managing the Pediatric Facial Fracture

Facial fracture management is often complex and demanding, particularly within the pediatric population. Although facial fractures in this group are uncommon relative to their incidence in adult counterparts, a thorough understanding of issues relevant to pediatric facial fracture management is critical to optimal long-term success. Here, we discuss several issues germane to pediatric facial fractures and review significant factors in their evaluation, diagnosis, and management.

Resorbable versus titanium plates for facial fractures

Rigid internal fixation of the jaw bones is a routine procedure for the management of facial fractures. Titanium plates and screws are routinely used for this purpose. The limitations of this system has led to the development of plates manufactured from bioresorbable materials which, in some cases, omits the necessity for the second surgery. However, concerns remain about the stability of fixation and the length of time required for their degradation and the possibility of foreign body reactions. To compare the effectiveness of bioresorbable fixation systems with titanium systems for the management of facial fractures. We searched the following databases: The Cochrane Oral Health Group's Trials Register (to 20th August 2008), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to 20th August 2008), EMBASE (from 1980 to 20th August 2008), http://www.clinicaltrials.gov/ and http://www.controlled-trials.com (to 20th August 2008). Randomised controlled trials comparing resorbable versus titanium fixation systems used for facial fractures. Retrieved studies were independently screened by two review authors. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated including both clinical and methodological factors. The search strategy retrieved 53 potentially eligible studies. None of the retrieved studies met our inclusion criteria and all were excluded from this review. One study is awaiting classification as we failed to obtain the full text copy. Three ongoing trials were retrieved, two of which were stopped before recruiting the planned number of participants. In one study, the excess complications in the resorbable arm was declared as the reason for stopping the trial. This review illustrates that there are no published randomised controlled clinical trials relevant to this review question. There is currently insufficient evidence for the effectiveness of resorbable fixation systems compared with conventional titanium systems for facial fractures. The findings of this review, based on the results of the aborted trials, do not suggest that resorbable plates are as effective as titanium plates. In future, the results of ongoing clinical trials may provide high level reliable evidence for assisting clinicians and patients for decision making. Trialists should design their studies accurately and comprehensively to meet the aims and objectives defined for the study.

Endoscopic Approach to Maxillofacial Trauma

Endoscopic approaches to maxillofacial trauma have included their use in temporomandibular joint arthroscopy, zygomatic arch repair, repair after orbital trauma, repair of frontal sinus fractures, and finally in the repair of subcondylar mandibular fractures. These techniques provide exciting new options for the management of facial fractures. Many of the techniques provide a steep learning curve and require specialized equipment. The approach to an orbital blowout fracture allows the use of a Caldwell-Luc approach and the use of a naturally occurring body space (the maxillary sinus) for the visualization and maneuvering of the endoscope, tools, and implants. The use of the endoscope in the management of fractures for facial structures such as mandibular subcondylar fractures, which do not have a naturally occurring body cavity, may present greater challenges when trying to obtain visualization, reduction, and fixation. When used for the treatment of subcondylar fractures, wide exposure and the use of right-angled drills and screw drivers may significantly help with this procedure. This may be considered by some surgeons as an endoscopically "assisted" procedure that can possibly be accomplished with direct visualization and the use of dental mirrors. It remains to be seen as to whether some of these diverse endoscopic applications will represent the standard of care in the future or remain a specialized technique practiced by a minority of surgeons in a few specialized centers. This article reviews various endoscopic applications to maxillofacial trauma and discusses some of the controversies of these techniques.

A Financial Analysis of Operative Facial Fracture Management

A Financial Analysis of Operative Facial Fracture Management

O.450 Intraoral treatment of malar fractures. Review of 150 cases

With little in the published literature on the conservative management of facial fractures we set out to determine whether our current criteria for treatment are valid.Two hundred and thirty adult patients with fractures of the facial skeleton were treated conservatively by our unit between February 1997 and January 2003. Their notes were reviewed retrospectively.Most patients were males (76%), the average age was 38 years, and drugs or alcohol were a significant aspect of the history in 30% of the cases. The most common mechanism of injury was assault (47%), followed by falls and sporting injuries. Fifty percent of the fractures involved the orbital or orbito-zygomatic complex, and 55% had associated injuries. Average follow-up was for six weeks (range 0–44 weeks). Most patients were managed conservatively based on our current criteria of un-displaced/minimally displaced fracture (57%); or minimal/no symptoms (24%). At final review, a number had residual symptoms, but only three required corrective surgery. The other reasons for conservative management included patient non-compliance (11%), and medical contraindications (8%).Our results support current indications for the conservative management of facial fractures, but emphasise the need for ongoing follow-up of these patients.

TWO YEARS REVIEW OF FACIAL FRACTURES AT A TERTIARY CARE HOSPITAL IN ISLAMABAD, PAKISTAN

OBJECTIVE: To present the experience of characteristics and management of facial fractures in a tertiary care Hospital in Islamabad, Pakistan. METHODS: Study was conducted in the department of Plastic Surgery at Pakistan Institute of Medical Sciences, Islamabad, Pakistan from January 2002 to December 2003. Only adult patients of either sex were included who presented with facial fractures. Patients below 12 years of age and those having only facial lacerations were excluded. In all cases, plain X-rays, OPG (Orthopantomogram), Water’s view and CT scan (in more severe cases) were obtained. Majority of the patients was operated on routine operation days (Monday to Saturday). All other fractures were managed by Open Reduction Internal Fixation (ORIF) via intra-oral approach (gingivobuccal incision). Only those fractures were approached from the external wound when the wound lied on the line of fracture. RESULTS: Total 133 fractures were noted in 96 patients. Most of the patients were males (76%) with a male to female ratio of 3.1:1. Mean age of the patients was 36.5 years (range 13 – 79 years). The commonest cause was road traffic accident (53.1%) followed by assault (21.9%). Mandible was the commonest facial bone to be involved (59.4%).. Various associated injuries were also noted in these patients with facial lacerations (29.9%) being the most common. Various treatment modalities were employed including Maxillo-Mandibular Fixation (n=37), lag screws (n=21), microplates (n=23). The most frequent complication was pain and or lower lip paraesthesia. CONCLUSION: Patients with these injuries must undergo early interventions including reduction and stabilization of fractures. Moreover, ORIF should also be undertaken wherever possible not through an external approach but the intraoral approach.

A Financial Analysis of Operative Facial Fracture Management

The financial impact of operative facial fracture management has not been systematically investigated. This study aims to provide a descriptive financial analysis of patients undergoing operative facial fracture management at a single academic medical center and the financial impact on the health system. The records of 202 patients who underwent operative facial fracture management over a 3-year period (2003 to 2005) were analyzed. All physician (professional) and hospital charges related to fracture management were included. Professional charges were subdivided by specialty and by payer type; hospital charges included operating room, recovery room, intensive care unit, hospital bed, supply charges, pharmaceuticals, laboratory charges, and radiographs. For comparison, similar data were obtained for the general plastic surgery population and for orthopedic surgery patients. The sum of all professional charges billed was $2,478,234 (average, $12,268 per patient). Collections for these professional services totaled $675,434, yielding an overall reimbursement rate of 27 percent. Reimbursement rates ranged from 38 percent for critical care physicians to 24 percent for surgery and neuroradiology. The highest collection rates occurred in children covered by the State Children's Health Insurance Program and in prison inmates (53 percent and 99 percent, respectively). The lowest collection rates were obtained from uninsured patients (10 percent total billing over collections). Total hospital charges were $18,120,027 (average, $89,703 per patient); the total collections were $2,770,115 (15 percent reimbursement rate). This study provides a descriptive financial analysis of operative facial fracture management. The unfavorable financial circumstances associated with facial trauma care may present a challenge to academic medical centers and plastic surgeons.

Applications of the Endoscope in Facial Fracture Management

The aesthetic necessity to preserve an undisturbed facial appearance and function has led to the progressive adoption of less-conspicuous incisions and decreasingly aggressive exposure in the treatment of facial injuries. The goals of proper anatomic reduction and stable fixation, however, must not be omitted. The introduction of endoscopic techniques has allowed a harmonious union of these two seemingly competing objectives. In condylar injuries, the endoscope may be used to restore preinjury condylar height and angulation, avoiding the feared risks of facial nerve injury and visible scarring. Treatment of complex zygoma and LeFort III fracture cases may be facilitated by repairing the zygomatic arch through remote stab incisions, obviating the need for an extensive coronal exposure. Endoscopically assisted treatment and diagnosis of orbital floor fractures decreases the risks of lower eyelid malpositioning without predisposing to the development of enophthalmos or hypoophthalmos. Similarly, depressed frontal sinus injuries may be reduced or camouflaged via hidden incisions, significantly reducing stigmata of surgical entry. In the overview to follow, the application of endoscope-assisted techniques to the treatment of the above fractures will be presented. The rationale for use, specific operative indications, bailout strategies, and outcome studies will be discussed.

Concomitant Injuries in Patients With Panfacial Fractures

Patients with panfacial fractures comprise a small portion of the overall facial fracture patient population. Because of the forces necessary to cause panfacial injury, these patients often have other concomitant injuries. The timing of operative facial fracture management remains controversial. A 3-year review of all patients with facial fractures was conducted at Duke University Medical Center (2003-2005, 437 total patients). All patients with panfacial fractures, defined as fractures involving at least three of the four facial segments (frontal, upper midface, lower midface, and mandible), were analyzed. Panfacial fractures were present in 38 patients (9% of overall facial fracture population). Twenty (53%) of these patients suffered concomitant injuries. The most common mechanism of trauma was motor vehicle collision, and the most common category of concomitant injury was intracranial injury or hemorrhage. Other commonly occurring categories of injury included abdominal organ injury, pneumothorax, pulmonary contusion, spine fracture, rib or sternum fracture, extremity fracture, and pelvic fractures. There was no significant difference in day of operation for the management of facial fractures between those with isolated facial injuries and those with other concomitant injuries (hospital day 2.1 vs. hospital day 2.9, not significant). Concomitant injuries to all parts of the body are found in patients with panfacial trauma. In our experience, these injuries do not significantly delay or have an adverse effect on the treatment of facial fractures. A treatment strategy for consistent timely management of facial fractures is described.

Utilization of Tracheostomy in Craniomaxillofacial Trauma at a Level-1 Trauma Center

The decision to perform a tracheostomy on patients with maxillofacial trauma is complex. There is little data exploring the role of tracheostomy in facial fracture management. We sought to profile the utilization of tracheostomy in the context of maxillofacial trauma at our institution by comparing patients who required tracheostomy with and without facial fractures versus those with facial fractures not requiring tracheostomy. All patients admitted to the Trauma Service at Legacy Emanuel Hospital and Health Center (LEHHC), Portland, OR, from 1993 to 2003 that sustained facial fractures or underwent tracheostomy were identified and data were retrospectively reviewed using patient charts and the trauma registry. Variables such as age, gender, death, injury severity score (ISS), facial injury severity score (FISS), Glasgow coma score (GCS), intensive care days (ICU), hospital length of stay (LOS), facial fracture profile, and oral and maxillofacial surgery (OMFS) operative intervention were tabulated and analyzed. Data were divided into 3 groups for comparison: group 1 (ffxT) consisted of patients who underwent a tracheostomy procedure and repair of their facial fracture during the SAME operation by the OMFS department (N = 125); group 2 (ffxNT) were those patients who had repair of their facial fractures by OMFS and did not require a tracheostomy (N = 224); and group 3 (NffxT) were patients who did not have facial fractures but received a tracheostomy during their hospitalization (N = 259). Ten-year data were used to analyze the ffxT and 5-year data were used to analyze the ffxNT and NffxT. Analysis of variance and chi2 testing was used for statistical analysis. A total of 18,187 patients were admitted to the trauma LEHHC Trauma Service during the study period, of which 1,079 (5.9%) patients sustained facial fractures and 788 (4.3%) required a tracheostomy. One hundred twenty-five patients (0.69% of total; 11.6% of facial fracture) received a tracheostomy at the same time as the facial fracture repair. All patients had their facial fractures successfully managed, regardless of the type of method used to stabilize the airway. There were no known cases of tracheal stenosis, severe bleeding requiring a return to the operating room, airway obstruction, or loss of secured airway. Males were the predominate gender in all 3 groups. The NffxT group (mean, 44.9 years) was much older compared with the ffxT (mean, 36.2 years) and ffxNT (mean, 30.9 years) groups. The incidence of death was higher in the tracheostomy groups compared with 0% with the non-tracheostomy group. The ffxNT group had a statistically significant higher GCS with an average of 12.4 when compared with the tracheostomy groups (ffxT = 6.8; NffxT = 6.7). ISS was nearly the same in the tracheostomy group (ffxT = 28.45; NffxT = 30.04), but higher when compared with the ffxNT (ISS = 17.33). All 3 groups were much different in terms of LOS and ICU days, in which the NffxT group had an average hospital LOS and ICU days of 34.4 and 16.56, respectively. This was higher when compared with the ffxT (LOS = 19.71 days; ICU = 7.21 days) and ffxNT (LOS = 6.82 days; ICU = 1.33 days) groups. The FISS averaged 6.22 in the ffxT group and was higher compared with an FISS of 3.16 in the ffxNT group. Overall, the fracture profile was different between the tracheostomy and non-tracheostomy groups. There was a higher prevalence of mandibular fractures, multiple mandibular fractures, and Le Fort III fractures in the ffxT group compared with the ffxNT group. Tracheostomy is commonly performed in the context of multisystem trauma and is a safe method for airway stabilization in patients with craniomaxillofacial trauma. Multi-institutional collaboration and a prospective, randomized trial measuring outcome, resource utilization, and length of ICU stay is necessary to determine if tracheostomy is indeed of measurable benefit to patients with complex injuries.

Management of Facial Fractures in the Deployed American Soldier

This article was written for the proceedings from a conference entitled 12th Annual San Antonio Trauma Symposium in San Antonio, Texas. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Wilford Hall Medical Center; email: [email protected].

The conservative management of facial fractures: indications and outcomes

With little in the published literature on the conservative management of facial fractures we set out to determine whether our current criteria for treatment are valid. Two hundred and thirty adult patients with fractures of the facial skeleton were treated conservatively by our unit between February 1997 and January 2003. Their notes were reviewed retrospectively. Most patients were males (76%), the average age was 38 years, and drugs or alcohol were a significant aspect of the history in 30% of the cases. The most common mechanism of injury was assault (47%), followed by falls and sporting injuries. Fifty percent of the fractures involved the orbital or orbito-zygomatic complex, and 55% had associated injuries. Average follow-up was for six weeks (range 0-44 weeks). Most patients were managed conservatively based on our current criteria of un-displaced/minimally displaced fracture (57%); or minimal/no symptoms (24%). At final review, a number had residual symptoms, but only three required corrective surgery. The other reasons for conservative management included patient non-compliance (11%), and medical contraindications (8%). Our results support current indications for the conservative management of facial fractures, but emphasise the need for ongoing follow-up of these patients.

Common Facial Fractures: 2. Management

This, the second of three articles, highlights the management of facial fractures and the GDP's role in this. For patients who present to dental practice with facial fractures, it is important that the dentist is able to inform the patient of his/her likely management in hospital.

O.241 Management and treatment of paediatric facial fractures: Our experience in a series of 320 fractures

O.241 Management and treatment of paediatric facial fractures: Our experience in a series of 320 fractures

Endoscopic management of facial fractures

Endoscopic applications in otolaryngology continue to expand, most recently in the area of maxillofacial trauma. Endoscopic management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures has been described. This paper reviews the current literature including new techniques, indications, and outcomes in endoscopic management of facial fractures. Very few large studies of endoscopic fracture repair exist. The current literature, however, suggests that, when compared with an open approach, smaller endoscopic incisions result in reduced patient morbidity with similar outcomes. Dedicated endoscopic instrumentation and novel surgical approaches continue to be developed. Endoscopic repair of facial fractures is a new and evolving technique that offers the potential for reduced patient morbidity and operating time, as well as quicker patient recovery. Current applications include the management of orbital blow-out, frontal sinus, zygomatic arch, and subcondylar fractures. It should be emphasized that endoscopy augments, rather than replaces, the 'time tested' principles of adequate skeletal exposure, accurate fracture reduction, and appropriate internal fixation.

Anaesthesia for facial trauma

The causes and types of facial injury are considered, specifically noting the way in which the different strength bones fracture and how they are classified in the Le Fort system. The early and late anaesthetic management of these cases is discussed with particular reference to potential airway problems. Emergency airway control and the different ways of controlling haemorrhage are described. Further management of the trauma patient with reference to the ABCDE priorities of basic life support and monitoring neurological deficit is then discussed. This is followed by information on other general issues of soft tissue injuries, pain control, prevention of infection and management of dural tears. The late management of facial fractures is different and can be complex. This article reviews the debate about the route of endotracheal intubation and gives some detail of submental intubation. The general principles of maintenance of anaesthesia are similar to those for neuroanaesthesia. Extubation strategies are discussed along with the requirement for high dependency recovery facilities.

Clinical recommendations for repair of orbital facial fractures.

Orbital facial fractures are a common result of facial trauma. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are debated. The timing and treatment indications for orbital facial fractures are evolving. For orbital floor fractures, nonresolving oculocardiac reflex, the "white-eyed" blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures, which may cause latent enophthalmos or hypo-ophthalmos. For midfacial, lateral, supraorbital, medial wall, and nasoethmoidal fractures, repair within 2 weeks is indicated to avoid difficult repair from immediate posttraumatic wound healing. Orbital facial fracture management is germane to ophthalmologists, plastic surgeons, otolaryngologists, and others who treat patients.