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Secondary Osteotomies of the Maxilla and Mandible, and Management of Occlusion

Background Unless there has been a loss of substance of portions of the maxilla and mandible, most traumatic disruptions of the maxilla and mandible are well corrected by placing the patient in the pretraumatic dental occlusion, plating the fractured segments with titanium miniplates and screws, and maintaining intermaxillary fixation where required. In extensive maxillary fractures, autogenous bone grafting is performed to reestablish the buttresses correcting the…

Secondary Midfacial Reconstruction

Background Secondary deformities resulting from complications in treating craniofacial injuries, specifically the midface, occur even when treated by experienced surgeons. Following proper surgical principles and recognizing the potential functional and aesthetic sequelae limits many complications. Ideal primary reconstruction is not always achieved. Displaced or missing bony segments result in an inadequate infrastructure, which interferes with the balance of the associated soft tissues. Lack of underlying support…

Secondary Orbital Reconstruction

Background Persistent enophthalmos and diplopia following primary orbital reconstruction lead to unsatisfactory aesthetic and functional outcomes, respectively. Diplopia after surgical repair of orbital fractures has been reported in 8%–52% of patients, while clinically significant enophthalmos has been reported in 27%. Large combined medial wall and orbital floor fractures tend to carry a higher risk of enophthalmos, particularly if the fracture compromised the inferonasal bony strut support.…

Posttraumatic Nasal Deformities

Background Nasal bone fractures are the most common type of facial fracture, and the third most common fracture of the human skeleton. Nasal trauma is often the result of motor vehicle collisions, sports-related injuries, altercations, and falls. The annual incidence has been estimated to be 53/100,000 in the United States, with the incidence of post-traumatic nasal deformity ranging from 14% to 50% if such fractures are…

Secondary Nasoethmoid Fracture Repair

Background High-energy midfacial trauma commonly results in naso-orbito-ethmoid (NOE) fractures, which present some of the greatest diagnostic and therapeutic challenges in facial trauma reconstruction. Fractures of the nasoethmoid region are defined as a midface fracture resulting in lateral displacement of the medial canthal-bearing segment of the medial orbital wall. These fractures may be isolated but frequently occur as part of more extensive “panfacial” fractures. The degree…

Ocular Considerations: Ectropion, Entropion, Blink, Ptosis, Epiphora

Background Approximately 2.4 million eye injuries occur each year. Ocular and periocular trauma can occur by a variety of mechanisms, some of the most common including assault and blunt trauma, motor vehicle collisions, gunshot, fireworks, and falls. The cumulative lifetime prevalence of eye injuries in the United States is approximately 1400 per 100,000 population. In one study, medical treatment was not sought for 18% of these…

Secondary Reconstruction of Facial Soft Tissue Injury and Defects

Despite the craniofacial surgeon's best efforts to minimize soft tissue disruption, secondary scarring and deformity are not infrequent following the treatment of facial injuries. These deformities may arise as a consequence of the trauma itself or may be an iatrogenic consequence of the exposure and soft tissue disruption required for facial fracture fixation. Such scarring and deformity are both functionally and psychologically disturbing to the patient…

Pediatric Cranial Reconstruction

Background Pediatric head trauma is a major source of morbidity, resulting in 600,000 emergency room visits annually within the United States. Between 10% and 30% of head traumas are associated with calvarial fractures, and of those greater than 50% have neurological injury. While the overall mortality rate from cranial fractures is low (2.9%), cranial trauma still accounts for 7000 deaths per year in the United States.…

Reconstruction of Full-Thickness Frontocranial Defects

Background Paul Manson, Bill Crawley, and Jack Hoopes in 1986 published a paper entitled “Frontal cranioplasty: risk factors and choice of cranial vault reconstructive material.” In that paper they examined their series of 42 cranioplasties, 25 of which were treated with methylmethacrylate (MMA), and 17 with autogenous bone. Both groups had about 60% preexisting infections. In the MMA group, there were no infections, and in the…

Pediatric Mandible Fractures

Background The topic of pediatric mandible fractures covers a wide range of patients with multiple clinical variables. Patients can range from a neonate with a mandible fracture stemming from birth trauma to an 18-year-old with full permanent dentition and multiple fractures. Because of this range of differences, the “pediatric” population in regards to mandible fractures can be further divided into the following: Neonate/infants – 0 to…

Pediatric Midface Fractures

Background The management of pediatric facial fractures presents some unique and specific opportunities that differ from those in the adult world. It is important to recognize that children are not small adults, and when possible, treatment should be conservative. There is no single approach to the management of midface fractures in children and care must be individualized. The dimensions of age and growth can add to…

Pediatric Orbital Fractures

Background Pediatric orbital fractures differ from the adult population in terms of presentation, management, and complications. The craniofacial skeleton undergoes significant anatomical and physiological changes from birth into adulthood; therefore, the fracture patterns in the pediatric population present differently, influencing diagnosis and management. The understanding of these injuries is evolving and controversial in some aspects: particularly the decision to operate and the timing of the operation.…

Superior Pediatric Orbital and Frontal Skull Fractures

Background and Incidence Within the pediatric age group, orbital fractures are among the most common facial fractures. Although pediatric craniofacial trauma remains relatively uncommon when compared to the adult population, it continues to cause significant morbidity and mortality. Orbital trauma can be caused by a range of mechanisms from low energy falls to high energy trauma caused by motor vehicles or sporting injuries. While orbital floor…

Pediatric Skull Fractures

Background Skull fractures are a common injury in the pediatric population and are often associated with significant morbidity and mortality. A strong foundational knowledge of pediatric skull fractures is essential for appropriate treatment and prevention of long-term complications. Although most skull fractures can be treated with conservative management, timely identification of more severe injuries can be life-saving. The surgeon should be comfortable identifying various fracture patterns…

Geriatric and Edentulous Maxillary and Mandibular Fractures

Through medical advances, the world's population is living longer and the geriatric age group is increasing. Edentulism is often associated with the geriatric population. Edentulism is defined as the condition of being without natural teeth. The edentulous population statistics are difficult to interpret fully and are related to multiple factors, including socioeconomic status. The rate of edentulism appears to be declining in the United States, however…

Characteristics of Ballistic and Blast Injuries

Introduction Ballistic injury patterns to the craniomaxillofacial region present a unique, and challenging, dilemma for the facial trauma surgeon. The tissue disruption associated with ballistic injury to the head and neck region can be daunting, and the identification of normal anatomic planes, potentially lost within bleeding, destroyed soft and hard tissues, can challenge the skills of even the most experienced facial trauma specialist. While classically considered…

Management of Panfacial Fractures

Background A panfacial craniofacial injury refers to fractures present simultaneously in the cranio-orbital (upper third), orbitozygomaticomaxillary (middle third), as well as the mandibular (lower third) portions of the craniofacial skeleton ( Fig. 1.19.1 ). This requirement of panfacial injuries to have fractures present in all three levels of the face is not consistently used among trauma studies, with some authors including patients with severe injury in…

Dentoalveolar Trauma

Background Dentoalveolar trauma represents a significant proportion of facial injuries. Treatment of dentoalveolar trauma has been documented as early as the era of Hippocrates, who described the use of dental splinting with bridal wires. Although many advances have occurred, the basic principles of fixation of loose teeth or bony segments to allow for hard and soft tissue healing are still paramount. The incidence and prevalence of…

Temporal Bone Fractures

The force required to fracture the temporal bone is substantial and can lead to vascular injury, hearing loss, vertigo or imbalance, facial nerve injury, and cerebral spinal fluid (CSF) leaks. This chapter will discuss the epidemiology of temporal bone trauma, the pathophysiology as well as complications, and current recommendations for management. Background Incidence Temporal bone fractures occur in 1%–9% of all head injuries, in 5% of…

Complications of Mandibular Fractures

The Problem The mandible is a complex structure involved in many functions. It is a hoop-like bone which gives form to the lower face. It supports the lower teeth, tongue, lips, and some of the muscles of facial expression. Through it runs the sensory innervation of the chin and lower lip. It is suspended in space by paired muscles of mastication which functionally move the jaw…