Midface osteotomies lines: Evolution by Paul Tessier,the second Tessier classification

The Tessier collection is an inheritance of a whole career of a surgeon and a life dedicated to cranio-facial malformations. It is a good opportunity to analyse some particular points of the surgical work of Paul Tessier, in particular to understand how the midface advancement procedures were made up and thought out. Medical files, pictures, X-rays and drawings help us to describe step by step the different types of midface osteotomies done by Paul Tessier, from TESSIER I to TESSIER VII osteotomies. The author describes the reason for the surgical lines and their modifications justified by all those files and by Tessier's personal annotations. Based on a single clinical case, Tessier experimented with new surgical procedures, firstly on skulls and dissection then the proposed surgery, the experience of the surgery and the post-operative result for each patient made him decide to change lines and procedures. At each step, the modification was done to improve stability, aesthetics, or to do the procedure in an easier way. Difficulties and mistakes were always new lessons for further patients.     

A spectrum of auditory canal injuries ensuing from direct or indirect trauma to the temporomandibular joint: A 2-year prospective study

This study aimed to assess various auditory canal injuries in patients with direct or indirect temporomandibular joint (TMJ) trauma, and, in collaboration with an otolaryngologist, evaluate the need for intervention. A prospective study was conducted at the institution. Patients who had sustained trauma to the TMJ were assessed for auditory canal injury through clinical and CT scan examination. All the patients were cross-consulted by an otolaryngologist for diagnosis and eventual management of any auditory canal injury. A close 3-month follow-up was carried out for all patients. Out of 32 cases (64 sides) of TMJ trauma, the following auditory canal injuries were documented: five cases (six sides) with tympanic plate fracture; five cases (five sides) with soft-tissue injury to the EAC; two cases (two sides) with tympanic membrane (TM) perforation; and one case (one side) with external auditory canal (EAC) hematoma (all p < 0.001). Corroborative results for the diagnosis of auditory canal injuries between the oral and maxillofacial surgeon (OMFS) and ENT surgeon were found to be statistically significant (p < 0.001). One case of tympanic membrane perforation required tympanoplasty and the rest were treated by conservative management. No complications were seen after 3 months of follow-up. To conclude, maxillofacial surgeons should perform a thorough bilateral ear examination to rule out any auditory canal injury in all the cases presenting with direct or indirect trauma to the TMJ. Timely management of such injuries should be undertaken by an otolaryngologist before TMJ trauma management to avoid any complications.     

Management of the trochlea of the superior oblique muscle in the repair of orbital roof trauma.

PURPOSE: This study evaluated whether reattachment of the trochlea is necessary to assure normal postoperative extraocular muscle movements after orbital roof exploration and trochlea detachment. PATIENTS AND METHODS: This was a retrospective review of 889 operative records of one surgeon practicing at a level I trauma center between January 1, 1992 and December 31, 1998. Three hundred twenty-four of these cases were trauma related, 97 of which involved the upper facial third or upper midface. From this group, 15 patients required orbital roof exploration with trochlea detachment. Age, gender, cause of injury, form of craniofacial injury, method of repair, materials used, date of first notation of intact extraocular movement, and date of last follow-up were recorded and analyzed. RESULTS: From among the 15 patients requiring orbital roof exploration and repair, 14 (93%) were male, with a mean age of 34.7 +/- 15.2 years. Eight (53%) were involved in motor vehicle accidents, 3 (20%) in motorcycle accidents, and 4 (27%) in high-energy impacts. Most (95%) had injuries that included the frontal sinus, the naso-orbital-ethmoid region (60%), and the orbital rims (60%). After bitemporal flap reflection, careful subperiosteal dissection, supraorbital and supratrochlear nerve repositioning, and trochlea detachment, simple reapproximation of the orbital soft tissues to the reconstructed orbit resulted in satisfactory extraocular muscle movements in all cases. CONCLUSIONS: When careful subperiosteal dissection is used, simple reapproximation of the soft tissues adjacent to the reconstructed orbital roof, without reattachment of the trochlea, is all that was necessary to assure satisfactory extraocular muscle movements postoperatively.     

British Association of Oral and Maxillofacial Surgeons’ National Facial Injury Surveys: hard tissue facial injuries presenting to UK emergency departments

The British Association of Oral and Maxillofacial Surgeons (BAOMS) and Saving Faces undertook two national prospective surveys 11 years apart. They recorded the facial injuries treated in UK emergency departments and collected data on 14 872 patients. In this paper, which aims to act as a feasibility study for a third national survey of facial injuries, we have reviewed hard-tissue injuries and specifically focused on temporal changes in their morphology. The two sets of directly comparable, categorical, unpaired, cross-sectional data were evaluated independently for statistical significance. In 1997, there were 1977 hard-tissue facial injuries (33%) but in 2008 this had decreased to 1899 (22%) (p < 0.05). In 1997, there were 1315 fractures (22%) and 662 dental injuries (11%) compared with 1462 (17%) fractures and 438 (5%) dental injuries in 2008 (p < 0.05). There were proportional increases in orbital (21%), nasal (139%), and cranial fractures (340%) (p < 0.05). The data showed a small reduction in the total number of hard-tissue injuries, but this was a considerable reduction as a proportion of the total injuries. Analysis of the type and subtype of injury generally pointed towards a reduction in their energy and severity, and to likely changes in mechanism. The project has proved the feasibility of a third national survey of facial injury.     

Classification and surgical management of orbital fractures: experience with 111 orbital reconstructions

Orbital skeletal injuries are frequently associated with other significant injuries and require a substantial surgical effort to correct. The use of a unified classification of orbital injury may better predict the surgical effort required to correct such injuries and help with future comparisons of results. In an attempt to summarize the principles of reconstruction of the orbital skeleton following trauma and introduce a unified classification system for orbital injuries, a retrospective review of all consecutive orbital reconstructions in a tertiary care teaching hospital was conducted. The nasoethmoidal region was involved in 32%, the zygomatic complex in 50%, and the frontal region in 28% of orbital fractures. Of the orbital walls, four walls were involved in 5%, three walls in 17%, two walls in 30%, and one wall in 53%. Associated ocular and neurologic injury was encountered in 33% and 57% of patients, respectively. Regions of fixation ranged from one to eight. Bone grafts were used in 20% and titanium mesh in 34% of the orbits. In general, the authors recommend an aggressive approach to orbital injuries, addressing all associated injuries simultaneously.     

Technical considerations of computer-aided planning in severe orbital trauma: A retrospective study

The aim of this study was to evaluate the clinical outcomes of linear and orbital volume measurements in severe orbital trauma. Patients with severe orbital trauma that involved more than two walls and entailed a marked degree of comminution were included in this retrospective analysis. However, patients with incomplete clinical records and a simple blowout or zygmatico-orbital fractures were excluded. All the cases underwent surgical correction guided by virtual surgical planning and 3D-printed templates. The measurement protocol depended on assessing orbital dimensions, orbital volumetry, and the zygomatic bone's position in the three-dimensional planes. All patients' preoperative 3D CT scans were obtained, and DICOM files were imported into a three-dimensional image processing software. Data were then converted for 3D reconstruction in the axial, coronal, and sagittal views. A total of 18 patients with a mean age was 39.28 ± 6.28 were included in this study. The results revealed a significant difference between the pre and postoperative differences in distances in relation to the FHP (Frankfurt Horizontal Plane) (P = 0.0014) and sagittal planes (P < 0.0001). The orbital width and height of the traumatized orbit were significantly decreased from 45.26 ± 6.72 mm and 45.30 ± 2.89 mm to 39.74 ± 3.91 mm (P = 0.0022), and 40.34 ± 0.86 mm (P < 0.0001), respectively. Clinically, there was a satisfactory degree of symmetry regarding the zygomatic bones' position and orbital dimensions postoperatively. Moreover, the mean orbital volume on the traumatized side decreased significantly from 23.16 ± 1.91 cm³ preoperatively to 20.7 ± 1.96 cm³ postoperatively (P < 0.0001). These findings were associated with a low incidence of complications. Within the limitations of the study it seems that the described methodology is a relevant addition to clinical treatment options. It incorporates all the latest technology to plan virtual reconstruction surgery in the treatment of complex orbital trauma and should be adapted accordingly in cases of severe displacement and comminution.     

Prevalence and severity of orbital blowout fractures

We aimed to study the prevalence of orbital blowout fractures and evaluate the causes and the location of orbital cavity fractures. In this cross-sectional study, the medical records of all patients admitted with facial trauma were assessed, sociodemographic information as well as the aetiology of trauma extracted, and the computed tomographic images of the patients were reassessed. Location of orbital blowout fractures and the severity of orbital fractures were evaluated. A total of 203 cases had blowout fractures (175 male and 28 female patients with a mean (SD) age of 36 (16) years. Road traffic accidents (n = 139, 69%) were the most common cause of orbital blowout fractures. Falls (n=29, 14%) and assault (n=20, 10%) were the other causes of trauma to the orbital structure, which resulted in blowout fractures. The medial wall was the most commonly involved location (n=81, 40%) followed by orbital floor (n=64, 32%), the combination of medial wall and floor (n=36, 18%), medial wall and maxilloethmoidal strut combination (n=13, 6%), and all the three locations altogether (n=9, 4%). Most of the blow-out fractures had mild severity (n=107, 53%). There was a significant relation between the severity and location of the blowout fractures (p < 0.001).     

Oral injuries in children attending a hospital in Saudi Arabia

Aims  To determine the occurrence, causes, types and severity of oral trauma and the time elapsed until seeking dental care in children seen in a hospital in Jeddah, Saudi Arabia. Materials and methods  Data included all cases of oro-facial trauma for children aged 17 years and younger who presented at the emergency and dental departments of the hospital during a 12-month period. Results  A number of 112 patients with traumatic oral injuries visited the hospital during this period. 79 were males and 33 were females. The highest frequency of injury was seen in 9–11 year old children. The most common cause of trauma was due to falls (68%). Most of the dental injuries occurred in the street (57%). The most common types of injury were luxation injuries and complicated crown fractures. Maxillary teeth were more affected than mandibular teeth. Maxillary central incisors were found to be the most affected teeth. 51 patients had soft tissue injuries and 13 patients had facial bone fractures. The largest number of injuries presented on the same day for treatment (70%) or 1 day after (36%). Conclusion  From the data this study population showed trends and comman cases of paediatric traumatic oral injuries senn in a major hospital in saudi Arabia.The study helpred us in improving awarness regarding the oral injuries and importance of minimizing its complication through educational programs     

Orbital bone fractures: 10 years’ experience at the Rome trauma centre: retrospective analysis of 543 patients

Orbital fractures are among the most frequent facial traumas. This study retrospectively analysed patients treated in Umberto I Hospital Trauma-Centre, Sapienza University of Rome from 1 January 2010 to 31 December 2020. The inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological records, and a minimum 12-month follow up. Gender, age, aetiology, fracture type, treatment, and associated complications were analysed using IBM SPSS Statistics, and p values of <0.05 were considered significant. In total, 1393 patients presented with orbital trauma, 543 of whom met the inclusion criteria and underwent surgery (394 males (72.6%) and 149 females (27.4%); mean (range) age 39.2 (7–90) years). Assault (n = 165, 30.4%) was the most common cause of trauma, followed by road traffic accidents and sports-related incidents. Diplopia was the major symptom at diagnosis (n = 183, 33.6%). Open reduction and internal fixation via a sub-eyelid approach was the preferred treatment, achieving a significant reduction in the functional changes induced by fracture (p < 0.05). Our data will aid future studies of maxillofacial traumatology and suggest that education and prevention measures could reduce the incidence of this type of trauma.     

Occurrence of tooth injuries in patients treated in hospital environment in the region of Araçatuba,Brazil during a 6‐year period

Abstract – Dental trauma has been considered as a public health problem that affects mainly children and youngsters and due to its impact on the patient’s quality of life. This study presents the results of a 6‐year survey of the occurrence and characteristics of dental trauma in patients admitted to the Service of Surgery and Oral and Maxillofacial Traumatology of the School of Dentistry of Araçatuba (UNESP, Brazil) after emergency care in hospital facilities in the region of Araçatuba, SP, Brazil. For such purpose, the clinical files of patients treated at the Service between 1999 and 2005 were reviewed. Information regarding gender, age, number of traumatized teeth, etiology and diagnosis of the trauma was collected from the files of patients with tooth injuries and recorded in case report forms specifically designed for this purpose. The results showed that from a total of 4112 patients admitted to the Service within the surveyed period, 266 (6.5%) had tooth injuries (172 males – 64.7%; 94 females – 35.3%). The total number of traumatized teeth was 496. Most patients belonged to the 16–20 year‐old age group (20.3%) and the most frequent causes of tooth injuries were bicycle accidents (28.6%), motorcycle accidents (19.2%) and falls (18.8%). Injuries to the periodontal tissues were the most frequent type of tooth injuries (408 teeth; 82.26%), occurring in 118 primary and 290 permanent teeth. Among the injuries to the periodontal tissues, avulsion was the most common (32.86%) (29.41% for primary and 34.0% for permanent teeth), followed by extrusive luxation (19.15%) (25.21% for primary and 17.24% for permanent teeth). In conclusion, in the surveyed population, cases of tooth injuries were more frequent in males aged 16–20 years old due to cyclist accidents with predominance of injuries to the periodontal tissues, in particular, avulsions.     

Association of craniomaxillofacial fractures and blunt cerebrovascular injuries

High energy trauma has been considered a risk factor for blunt cerebrovascular injuries (BCVI). The purpose of this study was to determine the incidence and risk factors for BCVI specifically in patients with maxillofacial fractures in an urban level I trauma center. A retrospective cohort study of patients aged ≥ 18 years, admitted to Massachusetts General Hospital (MGH) between 2007 and 2017, was implemented. There were 23,394 patients treated and entered into the MGH Trauma Registry: 22,287 sustained blunt trauma. Of the total blunt trauma patients, 68 (0.3%) had BCVI. There were 2421 patients with CMF fractures from blunt trauma (mean ± standard deviation age, 53 ± 22 years; 29.9% female included as study subjects, of whom 24 (1.0%) had BCVI). In a multivariate model, all mandible fracture (odds ratio (OR) 4.3, 95% confidence interval (CI) 1.6–11.6, P = 0.004), crush injury, defined as blunt compression injury (OR 11.1, 95% CI 2.1–58.1, P = 0.004), and cervical spine injury (OR 10.1, 95 CI 3.7–27.5, P < 0.001) were independent risk factors for BCVI. Mortality was 4.3 times higher in craniomaxillofacial fracture patients with BCVI versus those without BCVI; complications of BCVI (stroke) contributed to the majority of deaths. Appropriate screening and treatment of BCVI in patients with maxillofacial fractures is important.     

Orbital haemorrhage associated with orbital fractures in geriatric patients on antiplatelet or anticoagulant therapy

Retrobulbar haemorrhage is a sight-threatening condition that can occur after orbital trauma. The aim of this study was to evaluate the frequency and outcome of orbital haemorrhages following orbital fractures in geriatric patients receiving anticoagulants. All patients aged 65 years or more suffering from orbital fractures between 2008 and 2009 were included in this study. The mechanism of trauma, underlying diseases, and medication were recorded. In case of a retrobulbar haemorrhage, surgical exploration, the elapsed time between the onset of haemorrhage symptoms and surgical treatment, and the outcome regarding visual acuity were documented. Sixty-eight orbital fractures occurred (31 males, 37 females, age 65–95 years) resulting in six (3%) orbital haemorrhages. Four cases were associated with initial orbital bleeding, two other patients developed orbital haemorrhage as a complication after surgical reconstruction. Anticoagulant therapy, but not aspirin, was associated with a significantly increased risk of retrobulbar haematoma (p = 0.02). Two patients permanently lost vision, two partial recoveries and two total recoveries were observed. Patients receiving anticoagulants have a higher risk of orbital haemorrhage after orbital fracture and should be monitored closely. Any evidence of visual impairment should lead to further investigation and prompt treatment.     

Traumatic Dental Injuries: A seven-year evaluation of peadiatric cases seen in a tertiary hospital

BackgroundEarly presentation, prompt and adequate interventions of Traumatic Dental Injuries (TDIs) are necessary to prevent unwanted sequelae/complications.ObjectivesTo assess the pattern of TDIs among the affected children, identify the treatments received and the resultant complications/sequelae.MethodsThis was a retrospective review of dental records of all paediatric patients from December 2011 to December 2018. TDIs were recorded according to the WHO classification (1995). Information on the treatment received, clinical and radiographic sequelae of trauma were also retrieved. Data were analyzed using IBM SPSS software Version 22.ResultA total of 776 teeth (208 primary, 568 permanent) were traumatized in 513 patients (314 males, 199 females, mean age = 8.86 ± 4.04 years). The peak age at occurrence of trauma was 8 years. The majority of patients complained of broken teeth (51.5%), sustained injury at home (47.6%), had trauma due to a fall (88.7%) and presented after one year of trauma (27.3%). Three quarters of motorcycle accidents occurred in 6–12 year–old children. More young age groups sustained injuries at home compared with older age group (p = 0.000). Avulsion (26.1%) and uncomplicated crown fracture (38.2%) were the commonest injuries to primary and permanent dentitions respectively. The most common sequelae of trauma were pulpal necrosis followed by internal root resorption. Tooth extraction (42.8%) and root canal treatment (37.0%) were the commonest treatments given in both dentitions respectively.ConclusionThe pattern of TDIs appeared not to have changed considerably but motorcycle accidents contributed to the aetiology and pulpal necrosis was a major complication due to late presentation.     

Epidemiological aspects of dental trauma associated with maxillofacial injures: Ten years of clinical experience in Trieste,Italy

Background/Aims

The prevalence of dental injuries in patients with facial fractures is relevant. Epidemiologically, dental trauma in association with facial fractures generally affects the age group between 20 and 40 years old, with a higher prevalence in males. The aim of this retrospective study was to identify the incidence and etiology of dental trauma associated with facial fractures over a 10-year period.

Methods

From January 2009 to April 2019, among 381 patients with facial fractures, 353 were included in this study. Age, gender, trauma etiology, injured teeth and dental treatment were investigated.

Results

From 353 patients, with a mean age of 49.7 ± 19.9 years, 247 (70%) were males and 106 (30%) were females. Accidental falls were the most common type of injury (n = 118, 33.4%), followed by road accidents (n = 90, 25.5%), assaults (n = 60, 17%) and sports trauma (n = 37, 10.5%). Fifty-five subjects (15.60%) had dental injuries associated with facial fractures. Of the 145 teeth involved, 48 (33.1%) were diagnosed with luxation, 22 teeth (15.2%) were avulsed, 11 teeth (7.5%) suffered a concussion and there were 10 (6.8%) alveolar wall fractures.Uncomplicated enamel-dentin fracture was the more frequent hard tissue injury (n = 21, 14.5%), followed by complicated crown-root fracture (n = 10, 6.9%), infraction (n = 8, 5.5%), enamel fracture (n = 3, 2%) and complicated enamel-dentin fracture (n = 3, 2%). There was a peak in incidence between 21 and 40 years (42%). Males had a significantly higher risk of facial fractures with dental injury (75%). Maxillary incisors and canines (62.8%) were the most affected teeth.

Conclusions

There was a high prevalence of dental injuries associated with facial fractures. Maxillary incisors were the most injured teeth, with a higher prevalence in males.     

Blunt cerebrovascular injuries in the craniofacial fracture population—Are we screening the right patients?

Current knowledge of blunt cerebrovascular injuries (BCVIs) in craniomaxillofacial fracture (CMF) patients is limited. The purpose of this study was to determine the occurrence of BCVIs in patients with all types of CMF. This retrospective study included CMF patients in a level 1 trauma centre during a 3-year period. Patients who were not imaged with computed tomography angiography and patients with mechanisms other than blunt injury were excluded. The primary outcome variable was BCVI. A total of 753 patients were included in the analysis. A BCVI was detected in 4.4% of the patients screened. BCVIs occurred in 8.7% of cranial fracture patients, 7.1% of combined craniofacial fracture patients, and 3.1% of facial fracture patients. The risk of BCVI was significantly increased in patients with isolated cranial fractures (odds ratio (OR) 2.55, 95% confidence interval (CI) 1.18–5.50; P = 0.017), those involved in motor vehicle accidents (OR 3.42, 95% CI 1.63–7.17; P = 0.001), and those sustaining high-energy injuries (OR 3.17, 95% CI 1.57–6.40; P = 0.001). BCVIs in CMF patients are relatively common in high-energy injuries. However, these injuries also occur in minor traumas. Imaging thresholds should be kept low in this patient population when BCVIs are suspected.     

Maxillofacial injuries in western Iran: a prospective study

Introduction

Although the epidemiology of facial injuries has been studied in many populations, there is a paucity of information in the literature in this relation in the Middle East including Iran. The aim of this study was to assess the epidemiology and mode of treatment of facial injuries in western Iran.

Material and methods

We examined all patients with a maxillofacial injury who presented to the outpatient department or who were hospitalized in the Besat Hospital of Hamedan City, Iran, between 20 December 2007 and 20 December 2009.

Results

Of 2,450 patients (77% male, 23% female) with a facial injury, 90% sustained soft tissue injuries and 37% had bone fractures. Motor vehicle accidents (MVAs) were the most common cause of injuries (35%). The most frequent bone fracture occurred in the nasal bone (63.4%). The incidence of associated injuries was 8.3% (mostly orthopedic). Rigid internal fixation was the main treatment of facial fractures. Malpositioned zygomas and functional and aesthetic problems after reconstruction of nasal-orbital-ethmoid injuries were the most common postoperative complications.

Discussion

Although in many countries the rate of facial injuries due to traffic accidents is decreasing, MVA is still the major cause of facial trauma in Iran. This may be due to the lack of enforcement of traffic laws by police and insufficient compliance of the population in obeying traffic rules. Rigid internal fixation was the most common mode of treatment of facial fractures, and in spite of the severity of facial injuries, the rate of postoperative complications was relatively low.