RECENT ADVANCES IN

THE MANAGEMEN

T OF ORAL AND

MAXILLOFACIAL TRAUMA

M O D E R AT O R – D R . R A J A S E K H A R G .

P R E S E N T E D B Y-D R . S H E E TA L K A P S E

Contents Introduction Advances in primary care Mandibular fractures Midfacial and orbital fractures Nasal and frontal fractures Temporomandibular joint Military injuries and polytrauma Perioperative antibiotic prophylaxis Sports injuries Computer-Assisted Oral and Maxillofacial Surgery Advances in reconstruction Tissue engineering Conclusion References

Introduction

Young men have the highest risk of facial injury because of interpersonal violence and sport.

Alcohol and drug abuse are implicated in 15%-40%, and 47% of injuries, respectively.

Children from the lowest socioeconomic group are 1.89 times more likely to sustain a facial injury than those from the highest group.

Falls are the most common cause of facial injury in people over 60 and cause a large proportion of the total number of facial injuries.

Introduction No more than 24 hours of postoperative antibiotics are necessary after

repair of orbital and mandibular fractures as longer courses do not reduce infection rates further.

Perioperative steroids reduce postoperative nausea, vomiting, and swelling, and do not seem to impair healing through immunosuppression.

Emergency access to theatre is inadequate for patients with facial injuries and 30% of cases are delayed because others are more urgent.

The incidence of serious complications in patients with facial injuries who are operated on out-of-hours is over 3 times that of those operated on in-hours.

Advances in primary care

Minimally Invasive Surgery Endoscopic-assisted management of maxillofacial trauma has

been described for treatment of fractures of the mandibular condyle, the zygomatic complex, the orbit, and the frontal sinus.

However, with the use of endoscopic-assisted techniques, extraoral incisions can be limited or avoided in favour of intraoral approaches.

Intraoperative fixation after fracture reduction in areas of limited exposure and visibility can be obtained with these techniques.

(A)00 endoscope. The real and apparent fields of view are coincident, and the view does not change with rotation of the instrument.

(B) 300 endoscope. The field of view is greater as the instrument is rotated.

(C) 500 endoscope. Rotation of the instrument provides an even greater field of view, but there is a substantial central blind spot.

(From McCain J, editor. Principles and practice of temporomandibular joint arthroscopy, vol. 1. St. Louis (MO): Mosby; 1996

Mandibular Condyle Fractures The risks of facial nerve damage and extensive visible scars can be

minimized by minimally invasive endoscopic techniques with selected transoral approach.

For evaluation of quality of fractures reduction as well as for placement and removal of plates.

Transoral Approach

Midface Fractures

Transconjunctival Approach

Limited blepharoplasty incision

Transoral Approach

For diagnosis & evaluation of reduction of fracturesFor placement and removal of plates

Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a malar fracture. Ann Plast Surg 37:178, 1996

Orbital walls

Grasper and punch from straight to curve for endoscopic orbital surgery.

Special diamond drill (2 to 3 mm) and protective sheath for optic nerve decompression.

ENDOSCOPIC TECHNIQUES IN ORAL AND MAXILLOFACIAL SURGERY. Atlas Oral Maxillofacial Surg Clin N Am 11 (2003).

Frontal Sinus Fractures

Limited blepharoplasty incision

Approach through existing laceration

Incision 1 is marked in the midline.

Incision 2 is made in a line tangent to the lateral limbus of the eye.

Incision 3 is made perpendicular to a line from the nasomalar groove to the lateral canthus.

Mandibular fractures

Hiu GA, Prabhu IS, Morton ME, et al. Acrylated stainless steel basket splint for mandibular fractures in children. Br JOralMaxillofacSurg 2012;50:577–8.

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.

Condylar fractures

NarayananV, Ramadorai A, Ravi P, et al. Transmasseteric anterior parotid approach for condylar fractures: experience of 129 cases. Br JOral Maxillofac Surg 2012;50:420–4.

Pau M, Feichtinger M, Reinbacher KE, et al. Trans-tragal incision for improved exposure of diacapitular and condylar neck fractures. Int J OralMaxillofacSurg 2012;41:61–5.

Midfacial and orbital fractures Fractures of the orbital wall can

be treated conservatively when the defect is less than 3 cm 2 and when enophthalmos is less than 2mm and no soft tissue or muscle is trapped. (retrospective study on 48 cases)

Kunz C, Sigron GR, Jaquiéry C. Functional outcome after non-surgical management of orbital fractures–the bias of decision-making according to size of defect: critical review of 48 patients. Br JOralMaxillofacSurg 2013;51:486–92.

Even when the orbit is reduced completely, diplopia can persist because of adhesions from tethered scar tissue.

The considerable reduction in adhesions and scarring after insertion of the membrane (8 cases).

The epithelial side of the human amniotic membrane has an antiadhesive effect because of its smooth surface.

Rommel N, Rohleder NH, Gabriel C, et al. Secondary correction of post- traumatic orbital wall adhesions by membranes laminated with amniotic membrane. Br JOralMaxillofacSurg 2013;51:e224–9.

Polyglactin 910/ polydioxanone membrane coated with allogenic human amniotic membrane with amniotic epithelial side facing upwards.

• It provides anatomical fracture reduction with improved mechanical access, allows multiple reduction forces to be applied simultaneously, and avoids the need for repeated set-up before fixation.

Screw-wire traction technique: aid to anatomical reduction of multi-segment mid-facial fractures (Screw-wire osteo-

traction / SWOT)

’Regan B, Devine M. Screw-wire traction technique: aid to anatomical reduction of multi-segment mid-facial fractures. Br JOralMaxillofac Surg 2013;51:459–60.

• It can also give counter stability when drilling and tightening screws.

Devine M, O’Regan B. Screw-wire osteo-traction (SWOT) in the reduc- tion and fixation of frontonasal dysjunction in Le Fort II/III upper mid-facial fractures. Br JOralMaxillofacSurg 2013;51:985–7.

oodson ML, Farr D, Keith D, et al. Use of two-piece polyetherether- ketone (PEEK) implants in orbitozygomatic reconstruction. Br JOral Maxillofac Surg 2012;50:268–9.

Zygomatic implant

Stereolithographic model for orbital rim and floor implant

Two-piece orbital floor and rim implant

Two-piece

polyetherether- ketone

(PEEK) implants in

orbitozygomatic

reconstruction

The curved awl of the large suture passed under the zygomatic arch from below, exiting on the skin above the arch.

Two 2/0 resorbable sutures passed through the skin just below the zygomatic arch

Giudice A, Colangeli W, Cristofaro MG. . Percutaneous reduction of an isolated zygomatic fracture using a wire suture. Br JOralMaxillofac Surg 2013;51:e201–2.

The areas immediately superior and inferior to the fracture site are palpated but no local anaesthetic injected.

Iwai et al investigated whether intubation of the lacrimal system with a silicone tube during ORIF of displaced naso- orbitoethmoidal fractures prevented ductal blockage and epiphora.

The tube was removed 2–9 months.

Lacrimal intubation for at least 2 months may prevent epiphora caused by injury to thenasolacrimal system after fractures of the NOE complex.

Iwai T, Yasumura K, Yabuki Y, et al. . Intraoperative lacrimal intubation to prevent epiphora as a result of injury to the nasolacrimal system after fracture of the naso-orbitoethmoid complex. Br JOralMaxillofacSurg 2013;51:e165–8.

Nasal fractures The use of an anterior ethmoidal nerve block and dorsal periosteal injection

of anaesthetic solution during reduction of fractured nasal bones under general anaesthesia resulted in the effective reduction of postoperative pain.

H.-S. Kim, H.-K. Lee, H.-S. Jeong, H.-W. Shin: Decreased postoperative pain after reduction of fractured nasal bones using a nerve block of the anterior ethmoidal nerve. Int. J. Oral Maxillofac. Surg. 2013; 42: 727–731.

Frontal fractures In fractures of the frontal sinus, 3 findings on CT suggest obstruction of

the nasofrontal duct: fractures of the sinus floor or medial wall of the anterior table, and obstruction of the outflow.

If all 3 are present, there is a serious risk of injury to the outflow tract with a positive predictive value of 81%, so cranialisation or obliteration of the sinus is required.

When CT shows no evidence of obstruction the nasofrontal duct may be intact, which permits preservation and reconstruction of the frontal sinus.

YakirevitchA,BedrinL,AlonEE,etal. Relation between preoperative computed tomographic criteria of injury to the nasofrontal outflow tract and operative findings in fractures of the frontal sinus. Br JOral Maxillofac Surg 2013;51:799–802.

Frontal fractures Fractures of the anterior table can be accessed endoscopically with

incisions above the hairline.

Rao et al plated a fracture above the supraorbital rim through an incision in the upper eyelid crease. hey inserted screws using a 900 drill and screwdriver, and smoothed the defect in the contour with calcium phosphate cement.

Arcuri F, Baragiotta N, Poglio G, et al. Post-traumatic deformity of the anterior frontal table managed by the placement of a titanium mesh via an endoscopic approach. Br JOralMaxillofacSurg 2012;50: e53–4.

Rao J, Blackburn TK, Clark S, et al. Upper eyelid incision and use of a 900 screwdriver for osteosynthesis of fractures of the anterior table of the frontal sinus. Br JOralMaxillofacSurg 2013;51:974–5.

Temporomandibular joint In sheep Liu et al found that bony overgrowth occurs in the condylar head

following a sagittal fracture. The degree of overgrowth was reduced if the attachment of the lateral pterygoid was cut, suggesting that the pull of the muscle con- tributes to the remodelling of bone post fracture, which can result in overgrowth and subsequent ankylosis.

They were examined 19 TMJs using bilateral sagittal and coronal MRI, which were obtained immediately after injury to assess the displacement of the disc, whether there was a tear in capsule or the retrodiscal tissue, and whether there was an effusion in the joint.

They conclude that MRI is useful for diagnosis and for estimating the amount of damage to the TMJ, and is helpful in planning treatment

Yu YH, Wang MH, Zhang SY, et al. Magnetic resonance imag- ing assessment of temporomandibular joint soft tissue injuries of intracapsular condylar fracture . r JOralMaxillofacSurg 2013;51: 133–7.

Liu CK, Liu P, Meng FW, et al. The role of the lateral pterygoid muscle in the sagittal fracture of mandibular condyle (SFMC) healing process. Br JOralMaxillofacSurg 2012;50:356–60.

Operations for ankylosis –

i. Excision of the ankylotic mass

ii. Arthroplasty

iii. Osteotomy

iv. High condylectomy and resurfacing the joint with a costochondral graft

and repositioning of the displaced disc

v. 2-stage procedure ( removal of ankylotic mass and the joint reconstructed

later with a prosthesis)

Arakeri G, Kusanale A, Zaki GA, et al. Pathogenesis of post-traumatic ankylosis of the temporomandibular joint:a critical review. Br JOral Maxillofac Surg 2012;50:8–12.

He D, Yang C, Chen M, et al. Effects of soft tissue injury to the tem- poromandibular joint: report of 8 cases . Br JOralMaxillofacSurg 2013;51:58–62.

Kanatas AN, Worrall SF. Re: Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review . Br JOralMaxillofac Surg 2012;50:90–1.

N. N. Andrade, R. Kalra, S. P. Shetye: New protocol to prevent TMJ reankylosis andpotentially life threatening complications in triad patients. Int. J. Oral Maxillofac.Surg. 2012; 41: 1495–1500.

New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients

Military injuries and polytrauma

Breeze et al proposed a framework for the development of military neck

protection after an increase in the number of cervical injuries in the British

forces.

BreezeJ,MidwinterMJ,PopeD,etal. Developmental framework to validate future designs of ballistic neck protectiont. Br JOralMaxillofac Surg 2013;51:47–51

The British OSPREY neck collar is not

worn widely so development has begun to

interweave ballistic material into the collars

of body armour shirts.

Perioperative antibiotic prophylaxis1. Orbital fractures 2. ORIF for mandibular

fracturesfrom admission to

24 hours postoperatively

4 further days

amoxicillin with clavulanic acid

v/s

=

Evidences suggests that only 2 postoperative doses should be given

Sports injuries Protective headgear

Mouthguards in boxing - Mouthguards that are 6mm thick dissipate forces 4 times greater than those 2mm thick.

Helmets in cycling - the depth and density of the lining material rather than the shell governs how well a helmet will perform.

Thermoplastic splints manufactured using 3-dimensional scans of the face allow a quicker return to contact sport for players with a facial fracture.

KitturMA,DovgalskiLA,EvansPL,etal.Designandmanufactureof customised protectivefacialsportssplints. Br JOralMaxillofacSurg 2012;50:264–5.

helmet.mp4

Computer-Assisted Oral and Maxillofacial Surgery: Technology and Clinical Developments

DIAGNOSTIC IMAGING - CT, CBCT, MRI, USG

SEGMENTATION PROCEDURES - slice by slice

PLANNING AND SIMULATION

INTRAOPERATIVE SUPPORT

INTRAOPERATIVE IMAGING

POSTOPERATIVE EVALUATION

Passive tools for support of the intraoperative orientation Guiding systems (semiactive manipulator systems) Surgical robots will execute specific operative steps

DIAGNOSTIC IMAGING

Registration and fusion put the different imaging datasets—in this case, magnetic resonancetomography (MRT, above left) and computed tomography (CT, above middle)—into a commongeometrical context (fused imaging dataset with MRT in red and CT in green, above right).

The software makes it possible to represent the individual datasets and the fused dataset in different frames on themonitor.

PLANNING AND SIMULATION

Systems without technical support

Systems with passive support for intraoperative navigation

Systems with active support

INTRAOPERATIVESUPPORT APPLICATIONS

PROJECTION OF THE OPERATIVE PLAN ON TO THE PATIENT

INTRAOPERATIVE SUPPORT BY INSTRUMENT NAVIGATION

1. Mechanical systems2. Electromagnetic systems3. Ultrasound-based systems4. Optical coupling

REGISTRATION

• Additional reference frames using infrared diodes such as the operating instruments make it possible to move the operating table together with the fixated patient without having to repeat the registration.

• Surface-based scans for automatic registration of the patient’s position are increasingly mentioned.

Instrument set for passive optical navigation. The pointer and reference frame are rigidly fixed to the supraorbital rim for registration of the patient’s movements.

Robotic Surgery

Here are three surgical robots that have been recently developed:

1. da Vinci Surgical System2. ZEUS Robotic Surgical System3. AESOP Robotic System

A surgical console Patient-side cart Instruments and imaging processing equipment

Robotic_Surgery_Demonstration_Using_Da_Vinci_Surgical_System.mp4

According to the Robot Institute of America, 1979, a robot is a “reprogrammable multifunctional manipulator designed to move materials, parts, tools, or specialized devices through variable programmed motions for the performance of a variety of tasks.”

FDA approval for use in general

surgery since 1997.

Advances in reconstruction Six fields of computer-based craniofacial reconstruction were evaluated.

1. Secondary correction of panfacial fractures

Screen capture during navigated surgery with the virtually reconstructed CT dataset in multiplanar (coronal, sagittal, axial) and 3 D views.

The pointer (dotted lines) monitors the virtuallyreconstructed CT dataset to determine whether the advanced left globe matches the computer-assisted preplanned contour.

Advances in reconstruction

2. Traumatic enophthalmos with or without re-osteotomy and advancement of the malar bone

Axial computed tomographic images from the patient in Figure 33-13 showing theorbital region with corresponding bilateral orbital volumes before (A) and after (B) operation. Rightorbital volume was decreased by 5.2 cm3.

preoperatively, after simulation and postoperatively

Multiplanar and 3 D screen capture during navigated control of medial orbital wall augmentation. The tip of the pointer (dotted line) shows the correct reconstructed contour of the medial orbital wall compared with the mirrored dataset, resembling the ideal reconstruction. New position on top of the augmented calvarial grafts.

3. Optic nerve decompression in the treatment of traumatic optic neuropathy

4. Navigated endoscopic frontal sinus revision after severe skull base comminution.

Intraoperative overview during computer-assisted endoscopic surgery. A multiplanar and three-dimensional view of the same patient (inset) is available to the surgeon in real time. The tip of the dotted green line marks the tip of the tracked endoscope

5. Combined periorbital recontouring with computer-aided design and computer-aided manufacturing (CAD/CAM) of titanium implants and autologous bone grafts.

6. Recontouring of severe bone and soft tissue deformities by augmentation of the contours with alloplasts (e.g., calcium phosphate cement, titanium mesh)

Tissue engineering Tissue engineering is a rapidly advancing discipline that combines the

attributes of biochemical and biomaterial engineering with cell transplantation to create bio-artificial tissues and organs.

It aims to create tissue-matched, prefabricated, prevascularised bony or soft tissue composite grafts, or both.

Karl F.B.Payne, Indran Balasundaram, Sanjukta Deb, Lucy DiSilvio, Kathleen F.M. Fan. Tissue engineering technology and its possible applications in oral and maxillofacial surgery. British Journal of Oral and Maxillofacial Surgery 52 (2014) 7–15

Approaches to vascularisation of grafts in tissue engineering

Approach to vascularisation

Method of vascularisation Clinical technique

Prevascularisation in vivo Surgical angiogenesis

Two-step procedure: placing scaffold in vascular axis and transferring to site of

defect using microsurgery

Prevascularisation in vitro

Vasculogenesis within the scaffold

Seeding and co-culturing of endothelial and osteogenic cells on scaffold to form a vascular network within the bony construct

In situ vascularisation

(neovascularisation)

Intrinsic neovascularisation

Extrinsic neovascularisation

Axial vascularisation using arteriovenous loop embedded in scaffold at site of defect

Graft placed in defect, and neovascular network originates from periphery of

defect site

Conclusion

References1. Lee CH, Lee C, Trabulsy PP: Endoscopic-assisted repair of a malar fracture. Ann Plast

Surg 37:178, 1996

2. ENDOSCOPIC TECHNIQUES IN ORAL AND MAXILLOFACIAL SURGERY. Atlas Oral Maxillofacial Surg Clin N Am 11 (2003).

3. Hiu GA, Prabhu IS, Morton ME, et al. Acrylated stainless steel basket splint for mandibular fractures in children. Br JOralMaxillofacSurg 2012;50:577–8.

4. Kunz C, Sigron GR, Jaquiéry C. Functional outcome after non-surgical management of orbital fractures–the bias of decision-making according to size of defect: critical review of 48 patients. Br JOralMaxillofacSurg 2013;51:486–92.

5. Rommel N, Rohleder NH, Gabriel C, et al. Secondary correction of post- traumatic orbital wall adhesions by membranes laminated with amniotic membrane. Br JOralMaxillofacSurg 2013;51:e224–9.

References6. ’Regan B, Devine M. Screw-wire traction technique: aid to anatomical reduction of

multi-segment mid-facial fractures. Br JOralMaxillofac Surg 2013;51:459–60.

7. Devine M, O’Regan B. Screw-wire osteo-traction (SWOT) in the reduc- tion and fixation of frontonasal dysjunction in Le Fort II/III upper mid-facial fractures. Br JOralMaxillofacSurg 2013;51:985–7.

8. oodson ML, Farr D, Keith D, et al. Use of two-piece polyetherether- ketone (PEEK) implants in orbitozygomatic reconstruction. Br JOral Maxillofac Surg 2012;50:268–9.

9. Giudice A, Colangeli W, Cristofaro MG. . Percutaneous reduction of an isolated zygomatic fracture using a wire suture. Br JOralMaxillofac Surg 2013;51:e201–2.

10. Iwai T, Yasumura K, Yabuki Y, et al. . Intraoperative lacrimal intubation to prevent epiphora as a result of injury to the nasolacrimal system after fracture of the naso-orbitoethmoid complex. Br JOralMaxillofacSurg 2013;51:e165–8.

References11. H.-S. Kim, H.-K. Lee, H.-S. Jeong, H.-W. Shin: Decreased postoperative pain after reduction of

fractured nasal bones using a nerve block of the anterior ethmoidal nerve. Int. J. Oral Maxillofac. Surg. 2013; 42: 727–731.

12. YakirevitchA,BedrinL,AlonEE,etal. Relation between preoperative computed tomographic criteria of injury to the nasofrontal outflow tract and operative findings in fractures of the frontal sinus. Br JOral Maxillofac Surg 2013;51:799–802.

13. Arcuri F, Baragiotta N, Poglio G, et al. Post-traumatic deformity of the anterior frontal table managed by the placement of a titanium mesh via an endoscopic approach. Br JOralMaxillofacSurg 2012;50: e53–4.

14. Rao J, Blackburn TK, Clark S, et al. Upper eyelid incision and use of a 900 screwdriver for osteosynthesis of fractures of the anterior table of the frontal sinus. Br JOralMaxillofacSurg 2013;51:974–5.

15. Liu CK, Liu P, Meng FW, et al. The role of the lateral pterygoid muscle in the sagittal fracture of mandibular condyle (SFMC) healing process. Br JOralMaxillofacSurg 2012;50:356–60.

References

16. Yu YH, Wang MH, Zhang SY, et al. Magnetic resonance imag- ing assessment of temporomandibular joint soft tissue injuries of intracapsular condylar fracture . r JOralMaxillofacSurg 2013;51: 133–7.

17. Arakeri G, Kusanale A, Zaki GA, et al. Pathogenesis of post-traumatic ankylosis of the temporomandibular joint:a critical review. Br JOral Maxillofac Surg 2012;50:8–12.

18. He D, Yang C, Chen M, et al. Effects of soft tissue injury to the tem- poromandibular joint: report of 8 cases . Br JOralMaxillofacSurg 2013;51:58–62.

19. Kanatas AN, Worrall SF. Re: Pathogenesis of post-traumatic ankylosis of the temporomandibular joint: a critical review . Br JOralMaxillofac Surg 2012;50:90–1.

20. N. N. Andrade, R. Kalra, S. P. Shetye: New protocol to prevent TMJ reankylosis and potentially life threatening complications in triad patients. Int. J. Oral Maxillofac. Surg. 2012; 41: 1495–1500.

21. BreezeJ,MidwinterMJ,PopeD,etal. Developmental framework to validate future designs of ballistic neck protectiont. Br JOralMaxillofac Surg 2013;51:47–51

22. KitturMA,DovgalskiLA,EvansPL,etal.Designandmanufactureof customised protectivefacialsportssplints. Br JOralMaxillofacSurg 2012;50:264–5.