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Injury
journal homepage: www.elsevier.com/locate/injury
Review
A R T I C L E I N F O
A B S T R A C T
Article history:
Accepted 17 December 2008
Despite seat belt and alcohol legislation, craniofacial trauma still remains a common health problem and
signicant workload in many maxillofacial units. Although management has evolved considerably from
wiring teeth together, complex fractures can still result in cosmetic and functional deformity. Todays
challenge is to consistently restore patients back to their pre-injury form and functionbut this is not
always possible. Greater understanding and developments have signicantly improved outcomes,
although controversy still exists in some areas. This review outlines some of these topics.
2008 Elsevier Ltd. All rights reserved.
Keywords:
Maxillofacial
Trauma
ATLS
Developments
Controversies
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Applied biomechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mechanisms of injury and pathophysiology . . . . . . . . . . . . . . . . . . .
Soft tissues and fracture management . . . . . . . . . . . . . . . . . . . . . . .
ATLS and facial traumacan one size fit all? . . . . . . . . . . . . . . . . .
Timing of surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Imaging in facial trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surgical approaches to the facial skeleton . . . . . . . . . . . . . . . . . . . .
Repairing facial fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endoscopic repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Controversial topicsmanagement of the fractured Condyle56,60 . . . .
Controversial topicsmanagement of frontal sinus fractures25,58,65,136
Biomaterial developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Secondary correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Despite seat belt and alcohol legislation,59,78 craniofacial
trauma122 still remains a common health problem and signicant
workload in many maxillofacial units.141 Although management
has evolved considerably from wiring teeth together, complex
fractures can still result in cosmetic and functional deformity.
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Globe rupture.
Optic nerve transection.
Intraocular haemorrhage.
Intraocular foreign bodies.
Periorbital and orbital apex fractures.
The nature of any proptosis (oedema, haemorrhage, air, or bone).
1255
1256
Silicone.
P.T.F.E. (polytetraurorethylene).
Hydroxyapatite and other bone source.
Medpore (porous polyethylene54).
Titanium129.
Secondary correction
One of main challenges in maxillofacial trauma is to consistently
restore patients back to their pre-injury form and function. Despite
these advances and developments the harsh reality is that in a
signicant number of patients we still fall short of this standard.
This is more likely following high-energy trauma (comminuted
fractures and severe soft tissue injury), where treatment is delayed,
or complications develop. Secondary correction may then be
required. This has also benetted from many of the same
developments.
Crudely speaking tissues can be considered as missing (avulsion
injuries), excessive (hypertrophic scars, residual callus) or
displaced (nonanatomical repair). This simple approach helps
plan treatment. Detailed clinical assessment involves determining
both functional and aesthetic problems. This can be supplemented
with imaging usually CT. In addition to lms, dimensionally
accurate 3D models can now be fabricated109,125 Stereolithography134 and laser sintering are processes where model are made
from liquid light-cured monomer or plastic powder. Osteotomies
can then be performed, plates pre-bent and implant size and
shapes determined. By inverting images and using subtraction
techniques the difference between injured and non-injured side
can be calculated and custom implants fabricated without the need
for models. Computer-assisted guidance facilitates exact placement of these preformed implants through smaller incisions with a
reported accuracy of 1 mm. This is particularly useful in orbital and
cranial reconstruction. Unfortunately there are still limitations.
Metal and motion artefacts, partial volume effect and shrinkage of
the resin can contribute to inaccuracies. Reconstruction of
combined bone and soft tissue deformity is difcult due to
unpredictable soft tissue changes. New algorithms for soft tissue
reconstruction may solve these problems in the future.
Reconstruction of soft tissue defects is generally more difcult
than bone as soft tissue contraction increases the risks of relapse in
posttraumatic correction. A number of techniques are available
(e.g. injection of bone substitutes, onlays, or implantation of fat and
free tissue transfer). These are extremely technique dependent.
Summary
The management of the injured face has undergone major
changes following greater understanding of the healing process
and with advances in technology. Outcomes are considerably
better than 30 years ago as more comprehensive assessment and
management is now possible. Nevertheless the goal of consistently
restoring patients back to their pre-injury form and function still
eludes maxillofacial surgeons as in both our patients, and
ourselves, expectations have subsequently increased.
Conicts of interest
None.
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