June 1, 2011
by Archie Morrison, DDS, MS, FRCD(C)
Traumatic facial injuries are commonplace in North America. Interpersonal violence, falls, motor vehicle crashes and sport related injuries make up the majority of etiologies for these injuries.1 Since the advent of seat belts and air bags, there has been a significant decline in severe facial trauma as was seen in the ’60s, ’70s and ’80s.2 However, occasionally and unfortunately these injuries still occur. OMF surgeons on a regular basis deal with isolated facial fractures – mandibles, maxillae, zygomas, orbits, noses and frontal bones. For the most part these can be managed acutely, perhaps with the exception of nasal fractures where it can be helpful to wait for resolution of swelling since many of these are treated by closed reduction. Even the fractured zygomatico-maxillary complex can be managed and often treated from an intraoral approach, anatomically reduced and fixated in the presence of gross facial edema. The days of the ‘Gillies’ lift technique are being replaced by the intra oral buttress or other approaches with rigid fixation.3,4 These facial fractures are often thought of as easy fixes for OMF surgeons as it is simply a matter of putting the pieces of the puzzle back together; there is no occlusion to deal with!
Jaw fractures on the other hand represent a bigger challenge to achieve anatomic reduction such that the occlusion is normalized after the repair. This is especially so when rigid fixation (plates and screws) is utilized without a requirement for maxillo-mandibular fixation. Most patients, when offered the choice, would rather be ‘plated’ than ‘wired’ to fix their fractured jaw. On a regular basis we have seen patients referred to us with a fractured mandible or maxilla from their general dentist after that individual attended an emergency room and was sent home undiagnosed! After all some jaw fractures have slight or no displacement and the individual may look uninjured, however the complaint of a subtle malocclusion leads their dentist to suspect a fracture. In dental school education we encourage students/dentists to get involved in their community and offer help in diagnosing facial fractures when presented to local medical clinics or emergency rooms where there may be no OMF service. These cases can prove to be quite interesting and the service offered by dentists quite appreciated by the medical personnel and more so the patients.
For many patients that have had no ‘dental input’ with respect to their facial fracture repair the results are often less than acceptable to the patient – the most common complaint – malocclusion! (Figure 1) It is often difficult even for dentists to sort out what a normal occlusion is for a patient asleep on an operating table. Imagine someone with no dental training trying to figure that out!
When we encounter pan facial fractures, we start from the bottom and work our way up. If we can reestablish an intact mandible then this is the starting point for not only the occlusal relationship restoration but also for the vertical, transverse and horizontal (antero-posterior) dimensions of the face. A restored mandible leads to proper occlusion and then well aligned maxilla, followed by zygomas and orbits to be reconstructed.
Most lower and middle third facial fractures can be repaired from an intraoral approach. The mandible (with exception of the condyle), the maxilla, infra orbital rim and zygomatic buttress can all be explored and most times plated from inside the mouth. The upper facial skeleton is accessed via the bicoronal flap when necessary. These two approaches together can minimize the amount of surgical access scarring on the face itself. If the orbit needs attention, it can be accessed via a transconjunctival approach which is hidden inside the lower eyelid. Aside from a complex naso-orbito-ethmoid (NOE) fracture, the most difficult fracture on the face to anatomically reduce and plate from an intraoral approach is the angle of the mandible. Part of the reason for this is because the plate adaptation is tricky at best – a propeller like bend is often required and the occlusion is so sensitive that precision in reduction is difficult to achieve. If an extraoral approach is elected then the reduction and fixation is much easier.
The following case illustrates a nasty facial injury and the remaining work to be done deals with prosthetic replacement of one eye and maxillary and mandibular alveolar reconstruction followed by dental implant tooth replacement. Secondary to the young lady’s eye concern, her dentition and subsequent function is the most important rehabilitation for her.
The OMF service was called upon by the ICU Intensivist in June 2010 to assess a badly traumatized female patient whose car had hit a horse some six days earlier. She had been transferred to our local unit from a peripheral hospital after encountering a horse with her car on a secondary highway. This 22-year-old lady was driving her car at 11:30 at night when she hit a horse that had apparently escaped its paddock. Although she remembers nothing from about 10 minutes before the accident, it appears she struck the horse as it stood in the middle of the road. Alcohol was not a factor. It was some time before another vehicle showed up and the horse had been lying on the hood of the car with its feet in through the windshield and likely kicking her for some time while she was unconscious. Figure 2 illustrates her diagnostic 3D CT scan that was taken once she was stabilized in hospital. For some time she was kept under close watch in the ICU in Halifax prior to being cleared for surgery. All of her injuries were in the head and neck area.
Her inventory of injuries were as follows:
1. Compound comminuted fracture of mandibular symphysis;
2. Dentoalveolar fracture with avulsion and loss/near loss of teeth 4-2 through 3-3 inclusive and corresponding alveolus;
3. Fractured left condyle mandible;
4. Comminuted fracture maxilla – Lefort 1, 2 and 3 levels with split palate;
5. Dentoalveolar fracture with avulsion with loss/near loss of teeth 1-3 through 2-2 inclusive and corresponding alveolus;
6. Severe naso-orbital-ethmoid fracture;
7. Comminuted right and left zygomatico-maxillary-orbital fractures with gross displacement of the right side;
8. Gross displacement right orbital floor with ruptured globe and vision loss;
9. Depressed skull fracture right temporo-parietal area underlying displaced zygoma fragment
10. Underlying cerebral contusion right parietal lobe;
11. Stable spinous process fractures C-3,4,5;
12. Multiple facial lacerations (sutured over the initial days in ICU).
Remarkably, aside from her facial injuries and stable C spine fractures, she was totally uninjured. It was difficult at first to understand the mechanism of injury here but once it was discovered that the horse had been lying on the hood of the car kicking inside the cab, it made sense of the trauma. It had been otherwise suggested that nothing should be done to this young lady for 6 weeks. However we were of the opinion that the sooner she could have her fractures repaired the more predictable her outcome would be. Also if you delay these repairs that long you are midway in between doing acute fracture repair and doing osteotomies. The Intensivist who is also an Anesthesiologist at our hospital cleared her for a long operation. The family also was most anxious to have her injuries treated, as was she.
Two days following our initial consultation she was taken to the OR for a 12-hour procedure to reduce and fixate her multiple facial fractures. Ophthalmology had already operated on her right globe, suturing it back together but gave it a dismal prognosis. Because of its delicate condition we did not do any intra orbital bony work to the right orbit or the other one for that matter at the risk of
causing any globe injury, however slight it may be. All other fractures were reduced including the depressed skull fracture with no neurosurgical complications. (In these cases Neurosurgical consultation is had ahead of time and the usual response is for us to call them if the need arise.) This would usually be for persistent CSF leak but fortunately we had no trouble in that regard. We knew there would be future work to do via an orthognathic procedure on her maxilla to correct her occlusion since it was not possible to achieve maxillomandibular fixation at this time and orbital reconstruction depending on the outcome of the right eye. We also realized she would need bone grafting or distraction osteogenesis to replace her missing alveolar bone both in the mandible and maxilla and ultimately dental implant prosthetic rehabilitation.
Five months following her first surgery she was taken back to the OR in conjunction with Ophthalmology to reconstruct her right orbital floor and make a decision about her globe, which had now become a phthisicle. Once the orbital reconstruction was done, we performed a Lefort 1 osteotomy and placed her mutilated occlusion in a predetermined relation based on a dental work up for ultimate occlusal rehabilitation. A fat graft was also harvested to help restore a defect in the right temporal region where her zygoma had previously been displaced to lie over her depressed skull fracture. As well a vestibuloplasty was performed with skin graft in the anterior mandible for future prosthetic consideration.
A further surgery is planned at one-year post trauma to enucleate the right eye and prepare the soft tissue bed for a prosthetic eye (Ophthalmology) and to do bone graft reconstruction of the anterior mandible and maxilla. Figure 5 demonstrates the loss of alveolar bone in the anterior maxilla and mandible. After this everything should be able to be done in a clinical setting with local anesthesia +/- sedation, pending no complications with the upcoming surgeries.
While this young woman will never be the same, especially considering the loss of an eye, the goals of restoration of function and esthetics are the same for the OMF reconstructive surgeon, the ophthalmologist and the dental team. The best function that can be provided for all systems affected by the injury will be the goal. In this particular case the next most important piece of the puzzle (after her eye) is her dentition. From the time of acute injury repair this has to be considered in the plan so that when the time comes to do definitive repair, the foundation has been set as best it can be. For the majority of pan facial fracture patients malocclusions are the primary concern. Not everyone loses an eye! For sure we have our challenges ahead of us to rebuild her anterior bone and replace her teeth. If not for dental input by her care givers from the outset the challenge could be larger and the result less than ideal.OH
Dr. Morrison is an Associate Professor of Oral and Maxillofacial Surgery at Dalhousie University and Attending Staff at the QEII Health Sciences Centre and IWK Hospital for Women and Children in Halifax. He is also Director of Trauma Services at the Department of OMF at the QEII HSC.
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