Controversies in Maxillofacial Trauma

Controversies in Maxillofacial Trauma

Controversies inMODERATOR DR. RAJASEKHAR G.Presented by-Dr. sheetal kapse

INCLUSIONSINTRODUCTIONCURRENTCONTROVERSIESCONCLUSIONREFERENCESManagement of Fractures Through the Angle of the MandibleManagement of Condylar Process FracturesManagement of Comminuted Fractures of the MandibleManagement of Atrophic Mandible FracturesManagement of Mandibular Fractures in ChildrenManagement of Nasal FracturesManagement of Orbital FracturesManagement of Naso-Orbital-Ethmoidal FracturesManagement of Frontal Sinus FracturesFixation of zygomaticomaxillary complexSequencing of fixation in case of pan facial traumaManagement of Parotid Gland and Duct InjuriesUse of Prophylactic Antibiotics in Preventing Infection of Traumatic Injuries

INTRODUCTIONControversy can be defined as a dispute, generally with a right and a wrong side of the argument.

Controversy can also be defined as a discussion marked by the expression of opposing

When there are different approaches to surgical management, it is often not a matter of right or wrong, but rather what the surgeon believes gives the best results views.

1. Management of Fractures Through the Angle of the MandibleDoes the angle fracture have to extend through the Goinal Angle of mandible ??

Inclusion of different type of fractures in the same series.

Anatomic regionStart of fracture lineAnterior to gonionVertically and posteriorlyTo the gonionSlightly above itanteriorlyTension & compression zones change with different biting position and fracture lines.

Use of antibioticsTiming of treatmentTeeth in the fracture line

Ellis - 85% contained a third molar.Spiessl- lists three undesirable effects of extracting an unerupted tooth in the line of an angle fracture :The possibility of converting a closed fracture to an open oneLoss of the bony buttress on the tension side (superior surface)Loss of the possibility for inserting a tension band plateEllis E. Outcomes of patients with teeth in the line of mandibular angle fractures treated with stable internal fixation. J Oral Maxillofac Surg 2002;60: 8635.Soriano E, Kankou V, Morand B, et al. Fractures of the mandibular angle: factors predictive of infectious complications. Rev Stomatol Chir Maxillofac 2005; 106:1468.Spiessl B. Closed fractures. Chapter 5. In: Spiessl B, editor. Internal fixation of the mandible. Berlin: Springer-Verlag; 1989. p. 199.No difference in the rate of infection with closed reduction

Presence of a third molar associated with a fracture through the angle of the mandible increases the risk of infection irrespective of whether or not the tooth is erupted or impacted, or whether or not the tooth is removed during surgery.

Use of antibioticsTiming of treatmentTeeth in the fracture lineClose versus open reduction

Even when the fracture is not displaced, open treatment is usually provided so that internal fixationdevices can be placed to maintain the alignment of the fragments and obviate postoperative MMF.Only indication of MMF

Internal fixation schemesWire fixation + weeks of MMFOther fixation device without MMF

Bicortical screws & one large and one small bone plate, or two small plates

Good stability, infection

Bending/ torsional forces

Spiessl B. Closed fractures. Chapter 5. In: Spiessl B, editor. Internal fixation of the mandible. Berlin: Springer-Verlag; 1989. p. 199.Champy M, Lodde JH, Must D, et al. Mandibular osteosynthesis by miniature screwed plates via buccal approach. J Maxillofac Surg 1978;6:149.Levy FE, Smith RW, Odland RM, et al. Monocortical miniplate fixation of mandibular fractures. Arch Otolaryngol Head Neck Surg 1991;117:14954.Alkan A, Celebi N, Ozden B, et al. Biomechanical comparison of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral MedOral Pathol Oral Radiol Endod 2007;104:7526.Ellis E, Walker L. Treatment of mandibular angle fractures using two noncompression miniplates. J Oral Maxillofac Surg 1994;52:10326.

Internal fixation schemesPostoperative care

Force distribution through soft tissues explains why a single miniplate can be very successful in the management of fracture through the angle.

Association with co-existing fractures of mandibleComminuted angle fracturesRudderman RH, Mullen RL, Phillips JH, et al. The biophysics of mandibular fractures: an evolution toward understanding. Plast Reconstr Surg 2008; 121:596607.

requirement of additional fixationAntibioticsMouth wash & oral hygieneGap at the inferior borderUse of elastics

2. Management of Condylar Process FracturesParameters Closed reduction(3-6 weeks for adults & 10-14 days for children)Open reductionMIO (maximum interincisal opening)Equal or moreFaster rate of recoveryMovements Clinically acceptableFaster rate of recoveryOcclusion Chances of malocclusionMore satisfactory resultFacial contour No differenceNo differenceChin deviationNo difference - deviationLess incidencesPost treatment TMJ / masticatory muscle painFrequent painLess incidencesProcedure related complicationsIn particular medical situationsPresent

Laskin D M. Management of Condylar Process Fractures. Oral Maxillofacial Surg Clin N Am 21 (2009) 193196.

Zide MF, Kent JN (1983) Indications for open reduction of mandibular condyle fractures. J Oral Maxillofac Surg 41:8998.

DEGREE OF DISLOCATION & ANGLE OF DISPLACEMENTS

Mandibular condyle fractures evaluation of the Strasbourg Osteosynthesis Research Group classification

Mandibular condyle fractures evaluation of the Strasbourg Osteosynthesis Research Group classification11

EDWARD ELLIS III Symposium on condylar fractures 2004ABSOLUTE INDICATIONS- Displacement into the middle cranial fossa/external auditory meatus- Inability to obtain occlusion by non surgical/closed method- Invasion by foreign body- Lateral extra capsular displacement

RELATIVE INDICATIONS - Bilateral fractures in edentulous jaws- IMF contraindicated for medical reasons- Bilateral fractures associated with comminuted midface fractures- Severe periodontal problems & loss of teeth- patients desire to avoid IMF

Kang-Young Choi, Jung-Dug Yang, Ho-Yun Chung, Byung-Chae Cho. Current Concepts in the Mandibular Condyle Fracture Management Part II: Open Reduction Versus Closed Reduction. Arch Plast Surg.Jul 2012;39(4): 301308.

The problem with most comparative studies that have been reported is that they are generally retrospective rather than prospective and that there is considerable variation in the patient selection and outcome criteria used as well as in the follow-up time.

Therefore, until better-designed comparative studies are available that will allow evidence-based decisions to be made, one can only look at individual case series for some guidance.

3. Management of Comminuted Fractures of the Mandible5-7 % of all mandibular fractures, usually compound type.

Joe Hall Morris appliance for comminuted fracture of the symphysis

Traditional conservative managementMMF + external fixatorLong healing periodRestricted functionMorbidity

MMFRoger Anderson appliance controlling multiple comminuted mandibular fractures.Indications

Significant head injury

Necessary equipments are not available

5-7 % of all mandibular fractures, usually compound type. MMF + external fixators 70 years (WW I, WWII, Korean war, Vietnam war.)18

OPEN REDUCTION AND INTERNAL FIXATION

Load bearing reconstruction plateDecreases healing timePost op MMF is not requiredNo scarring of skinGood functional out comeTechnical pointsStabilize the teeth and alveolus with arch barsIntact lingual periosteumSimplification of fractureTechnical pointsReconstruction plate with 3-4 screws on either side of fracturesDefect closure with bone graft

4. Management of Atrophic Mandible FracturesClosed reduction techniques for atrophic edentulous mandible fractures

1. Gunning splints with arch bars2. Circummandibular wiring of oblique fractures3. External fixatorAnterior and posterior pin connected by a transverse bar spanning the fracture4. No treatment / soft diet

Many oral and maxillofacial surgeons are inexperiencedin managing such injuries because theyoccur so rarely. In addition, because of this infrequency,surgical literature offers little updatedinformation about management.20

IndicationsApproaches (intraoral - vestibular/ extraoral)Open reduction and internal fixation techniques for atrophic edentulous mandible fractures

Fixation with

Reconstruction plateLocking / non-locking minplatesTitanium or other mesh crib with autograftsLag screwAlloplastic materials

Hydroxyapatite, Tricalcium phosphate, Glass ceramics, Glass carbonateInjectable calcium phosphate cements

Future materials

Gene therapyTissue engineering

5. Management of Mandibular Fractures in ChildrenDiagnosis because of child co-operationFracture pattern & displacement of segments Open versus closed reduction and closed functional treatmentDuration of MMFRole of other treatment modalitiesTitanium, stainless steel or bioresorbable materials for fixation

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Hiu GA, Prabhu IS, Morton ME, et al. Acrylated stainless steel basket splint for mandibular fractures in children. Br JOralMaxillofacSurg 2012;50:5778.The occlusion was satisfactory, without infection or malocclusion. None required revision, and there was no deviation of the mandible, ankylosis, or disturbances of growth.Five children with mandibular fractures were treated with a split acrylic splint, which secured the fracture by wiring around the mandible.

6. Management of Nasal FracturesTIMING OF NASAL FRACTURE TREATMENTIf a patient is seen shortly after trauma, before significant edema developsLacerations with exposure of the underlying skeletal or cartilaginous elements

Presence of a septal hematomaWithin the first 10 days of injury are less likely to require a revision septorhinoplasty

Local v/s general anesthesiaIn the presence of minor nasal bony deviation and no associated septal or nasal tip displacement, closed reduction under local anesthesia has been suggested as the first line of treatment.

Complex or severely displaced fractures may require treatment under general anesthesia.

OPEN V/s CLOSED TECHNIQUESClosed reductions - most acute isolated nasal fractures with minimal bony and septal injury (within 10 days).Internal packing for 3 days & external for 7 to 10 days.14% to 50% cases - Postreduction deformities - secondary rhinoplasty.The final decision - condition of the septum and the need to preserve the connection between the septum, upper lateral cartilages, and nasal bones.

Denver splint.

Outcomes of nasal fracture treatment may be compromised by the fact that late morphologic changes can occur over 1 or more years because of scarring.

7. Management of Orbital FracturesINDICATION FOR SURGICAL REPAIR OF ORBIT

Lack of ocular motility

Diplopia : Surgery may increase the risk of diplopia, at least temporarily.

Enophthalmos : define this as greater than 1 cm3 & greater than 2.0 mm typically indicates the need for surgical

Ahn HB, Ryu WY, Yoo KW, et al. Prediction of enophthalmos by computer-based volume measurement of orbital fractures in a Korean population. Ophthal Plast Reconstr Surg 2008;1:369.There seems to be a direct relationship between the increase of orbital volume and measured enophthalmos.

Volume increase of < 1 mL, enophthalmos ~ 0.9 mm, Volume 2.3 mL ~ 2 mm.

For every 1 mL increase of volume there is approximately a 0.9 mm increase in enophthalmos.

However, in normal orbits, there can be a natural volume difference of up to 8% between the left and right sides.

TIMING OF ORBITAL SURGERY

Dortzbach and later Leitch and coworkers : surgery for orbital floor fractures within 14 and 21 days after trauma.

Cole and coworkers : gave indications for immediate repair

Trumatic optic neuropathy (alteration in visual acuity & color desaturation test)Occulocardiac reflexPenetrating injuriesAge younger patients

USE OF STEROIDS : Corticosteroids can be used as the only treatment if the visual acuity is better than 20/400Cole P, Boyd V, Banerji S, et al. Comprehensive management of orbital fractures. Plast Reconstr Surg 2007;120:5761.Hawes MJ, Dortzbach RK. Surgery on orbital floor fractures: influence of time of repair and fracture size. Ophthalmology 983;90(9):106670. Leitch RJ, Burke JP, Strachan IM. Orbital blowout fractures: the influence of age on surgical outcome. Acta Ophthalmol 1990;68:11824.

4. MATERIALS FOR RECONSTRUCTIONPotter JK, Malmquist M, Ellis E III. Biomaterials for Reconstruction of the Internal Orbit. Oral Maxillofacial Surg Clin N Am. 2012; 24 (4):609627.

Titanium mesh is used in mandibular reconstruction to improve stability of bone grafts, in reconstruction of anterior wall of frontal sinus and orbital reconstruction as the metal is more biocompatible32

Abbreviations: FF, very favorable; F, favorable; U, unfavorable; UU, very unfavorable.

Abbreviations: BAG, bioactive glass; FF, very favorable; F, favorable; HA, hydroxyapatite; PDS, polydioxanone; PGA, polyglycolide; PLA/PGA, polylactide/polyglycolide; PLDLA, poly L/D lactide copolymer; PLLA, poly L lactide; Sil, silicone; Tef, Teflon; Tit, titanium; U, unfavorable; UU, very unfavorable.

8. Management of Naso-Orbital-Ethmoidal FracturesNOE fractures rarely occur as isolated events.

Extent of fracture : NOE fractures associated with panfacial injuries are associated with a diffuse facial edema, whereas isolated NOE fractures are associated with localized ecchymosis and edema in the nasal and periorbital regions.

Requirement of treatment : examination of canthus containing fragments and telecantus

Associated injures often include central nervous system injury, cribriform plate fracture, cerebrospinal fluid rhinorrhea, and fractures of the frontal bone, orbital floor, and middle third of the face, as well as injury to the lacrimal system.

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Early versus late management : waiting no more than 2 weeks.Closed versus open reduction : indications, approaches, fixationPosition of reattachment of medial canthus

9. Management of Frontal Sinus FracturesRepair Obliteration (ablation)CranializationPreservation of the sinus anatomy, including the nasofrontal duct, sinus mucosa, and its anterior and posterior bony wallsObliteration involves the elimination of the frontal sinus cavity while maintaining the anterior and posterior tablessimilar to frontal sinus obliteration with the exception that the posterior table is completely removedNo treatment

Volume of material needed is highly variable, averaging approximately 35 to 40 cm3 to as much as 200 cm3

Endoscopic-Assisted Repair

10. Fixation of zygomaticomaxillary complexRodrigo Otvio Moreira Marinho, Belini Freire-Maia. Management of Fractures of the Zygomaticomaxillary Complex. Oral Maxillofacial Surg Clin N Am 25 (2013) 617636.Zingg M et al Classification of ZMC fractures. (A) Type A1: isolated zygomatic arch fracture. (B) Type A2: lateral orbital wall fracture. (C) Type A3: infraorbital rim fracture. (D) Type B: complete monofragment zygomatic fracture. (E) Type C: multifragment zygomatic fracture.

Judgement of fracture reductionZygomaticosphenoid sutureZygomaticomaxillary buttressInfraorbital rimFrontozygomatic suture

Priority of fixationZygomaticomaxillary buttressFrontozygomatic sutureInfraorbital rimZygomatic archSequence of fixationFrontozygomatic sutureInfraorbital rimZygomaticomaxillary buttressZygomatic arch

11. Sequencing of fixation in case of pan facial trauma

Classical approaches

bottom up and inside outtop down and outside in

Booth PW, Eppley BL, Schmelzeisen R, editors. Maxillofacial trauma and esthetic facial reconstruction. Philadelphia: Saunders; 2012.

bottom up and inside outIt predates the use of rigid fixation but it is still a valid approach. It establishes the mandible as a foundation for setting the rest of the face and includes open reduction and internal fixation of subcondylar fractures, as well as the remainder of the mandible.

bottom up and inside out

top down and outside inOpen treatment of the condyles may not be necessary.The patient is treated with varying periods of MMF fixation, which may be a valid approach in the case of comminuted intracapsular fractures.There are two potential complicationsunrecognized rotation of the body or ramus of the mandible, resulting in widening. Temporomandibular joint ankylosisCaused by the inability to begin early physical therapy. Early function of patients with condylar head fractures is usually indicated, along with guiding elastics to maintain the range of motion of the temporomandibular joint.

top down and outside in

This approach uses a stable fronto-orbital frame from which to proceed inferiorly and outside-in.

Working from a known or stable area (less isplacement or comminution) and proceeding to an unknown area can make proper reduction more manageable and achievable.

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12. Management of Parotid Gland and Duct InjuriesDIAGNOSIS : Use of dye - excessive extravasation from the lacerated duct may complicate surgery.Saline can be injected if difficulty is encountered in finding the proximal end. No fluid seen in the wound indicates that the duct is intact.

TIMING OF REPAIR :Done early, preferably in the first 24 hours.Late complications, such as a parotid fistula, are difficult to treat.

WOUND CLOSURES WITHOUT DUCT REPAIR

MANAGEMENT OF INJURIES TO THE GLAND AND DUCTRepair of the injury, putting a stent in the duct, and placing a pressure dressing, botox in chronic cases.

Injury to the duct - repair of the duct over a stent, ligation of the duct, or fistulization of the duct into the oral cavity.

Injury of the duct orifice - insertion of a drain.

Leaving the stent in place after duct repair subsequent swelling can cause obstruction of duct

Use of an autogenous graft for repair of continuity defect of duct

14. Use of Prophylactic Antibiotics in Preventing Infection of Traumatic InjuriesPROPHYLACTIC ANTIBIOTICS IN PATIENTS WITH SKIN WOUNDS

According to the principles of presurgical prophylaxis, antibiotics, if they are to be given at all, should be administered as soon as possible after the injury, if possible within the first 3 hours and continued for 3 to 5 days.

Staphylococcus aureus and streptococci : Cloxacillin and first-generation cephalosporins

Open joints or fractures Human or animal bitesIntraoral lacerationsHeavily contaminated wounds (eg, those involving soil, feces, saliva or other contaminants).Patients who have prosthetic devices and at risk for developing endocarditis.Systemic antibiotics also are recommended when there is a lapse of more than 3 hours since injury, Lymphedematous tissue involvement, Host is immunocompromised.INDICATIONS

The primary goal in the management of traumatic wounds is to achieve rapid healing with optimal functional and esthetic results.

This is best accomplished by providing an environment that prevents infection of the wound during healing51

USE OF PROPHYLACTIC ANTIBIOTICS FOR PREVENTION OF INFECTION OF INTRAORAL WOUNDSthrough-and-through lacerations - a course of prophylactic antibiotics to prevent infection after these wounds are repaired.

TOPICAL ANTIBIOTICS FOR TREATMENT OF TRAUMATIC WOUNDSOintments - bacitracin, neomycin, or polymyxin have been routinely used.

The primary goal in the management of traumatic wounds is to achieve rapid healing with optimal functional and esthetic results.

This is best accomplished by providing an environment that prevents infection of the wound during healing52

ANTIBIOTIC PROPHYLAXIS IN PATIENTS WITH OPEN FRACTURES AND JOINT WOUNDS

Classification Of Open Fractures And Joint

Type ofDescription Involved pathogensEmpirical antibioticsIIs an open fracture with a skin wound that is clean and less than 1 cm longS aureus, streptococciSpp, and aerobic gram-negative bacilliFirst- or second-generationCephalosporin

within 6 hours + 24 hours postopIIAn open fracture with a lacerationThat is more than 1 cm long, but without evidence of extensive soft tissue damage, flaps, or avulsionIIIAn open segmental fracture orAn open fracture with extensive soft tissue damage or a traumatic amputation

Certain environmental exposuresMore no. Of gram negativeOrganisms

Clostridium, Acinetobacter, Pseudomonas, Clostridium, Aeromonas, Pseudomonas, Aeromonas, VibrioCephalosporin & aminoglycoside

Penicillin

within 6 hours + 24 hours postop

The primary goal in the management of traumatic wounds is to achieve rapid healing with optimal functional and esthetic results.

This is best accomplished by providing an environment that prevents infection of the wound during healing53

Why there is controversy ??clinical studies fail to demonstrate a lower infection rate among patients with uncomplicated wounds treated with prophylactic antibiotics

studies have assessed their efficacy after suture wound closure

CONCLUSION In the treatment of many kinds of traumatic injuries of the Maxillofacial region, too few randomized, controlled studies are available to supply strong supporting evidence for definitely selecting one surgical technique or procedure over another. Therefore, we have to rely upon expert opinion, as well as the literature, to guide us in the decision-making process.

REFERENCESOral Maxillofacial Surg Clin N Am 21 (2009). doi:10.1016/j.coms.2009.01.001Jiewen Dai, Guofang Shen, Hao Yuan, Wenbin Zhang, Shunyao Shen, Jun Shi. Titanium Mesh Shaping and Fixation for the Treatment of Comminuted Mandibular Fractures. J Oral Maxillofac Surg 74:337.e1-337.e11, 2016.Booth PW, Eppley BL, Schmelzeisen R, editors. Maxillofacial trauma and esthetic facial reconstruction. Philadelphia: Saunders; 2012.William Curtis, Bruce B. Horswell. Oral Maxillofacial Surg Clin N Am 25 (2013) 649660.