Manejo de las fracturas maxilofaciales y sus complicaciones / Management of maxillofacial fractures and its complications

RESUMEN Antecedentes: el trauma maxilofacial corresponde a toda lesión traumática del macizo facial. Actualmente representa uno de los problemas de salud más importantes en el mundo. Nuestro objetivo es realizar un análisis de nuestra experiencia en las intervenciones realizadas en pacientes internados y sus complicaciones. Material y métodos: se realizó un estudio descriptivo, retrospectivo y observacional de 205 pacientes con fracturas maxilofaciales desde el año 2011 hasta el año 2019. Resultados: el 81,46% fueron hombres (n: 167) y el rango etario más afectado osciló entre los 21 y 30 años con el 38,54% (n:79). El accidente de tránsito 56,1% (n:115) fue el mecanismo de trauma más frecuente. Los tipos de fracturas faciales fueron: panfaciales 12,2% (n: 25), tercio superior 1,46% (n:3), tercio medio 72,2% (n:148) y tercio inferior 14,15% (n:29). Dentro del tercio superior, el 66,67% (n:2) fueron fracturas del seno frontal asociadas al hueso frontal, en el tercio medio las combinadas en un 54,73% (n:81) y en el tercio inferior, las complejas en el 34,48% (n:10). Fueron intervenidos 199 pacientes (97,07%). Solo el 11,56% (n:23) presentó alguna complicación. No se observaron complicaciones graves. Discusión: según nuestra serie, la mayoría de los pacientes fueron hombres jóvenes; la causa más frecuente, el accidente de tránsito, y el tercio medio, el más afectado, resultados estos similares a los de otros estudios publicados. El tratamiento quirúrgico fue principalmente reducción abierta y fijación con material de osteosíntesis de titanio, un procedimiento seguro y fiable, que permite restablecer la funcionalidad previa al traumatismo, con un índice muy bajo de complicaciones posoperatorias.

ABSTRACT Background: Maxillofacial trauma corresponds to all traumatic injuries affecting the facial bones. Nowadays, it represents one of the main healthcare issues worldwide. The aim of this study is to analyze our experience in the interventions performed in hospitalized and their complications. Material and methods: We performed a retrospective and observational study of 205 patients with maxillofacial fractures from 2011 to 2019. Results: 81.46% were men (n = 167) and 38.54% (n = 79) of the patients were between 21 and 30 years of age. Traffic collision was the most common mechanism of trauma (56,1%, n = 115). The types of facial fractures were panfacial (12.2%; n = 25), of the upper-third (1.43%; n = 3), of the middle-third (72.2%; n = 148) and of the lower third (14.15%; n = 29). In the upper third of the face frontal sinus fractures associated with the frontal bone were the most common (66.67%; n =2); in the middle-third combined fractures were most prevalent (54.73%; n = 81) while complex fractures were most frequent in the lower third (34,48%; n = 10). One-hundred and ninety-one patients were operated on (97.07%). Complications occurred in only 11.56% (n = 23) and were not serious. Discusion: In our series, most patients were young men, traffic collisions were the most common cause of trauma, and the middle third of the face was the most affected region. These results are similar to our publications. Surgical management, mostly by open reduction and fixation with titanium-based osteosynthesis material, is an effective, safe and reliable procedure, which allows the restoration of pre-trauma function, with very low rate of postoperative complications.

Trauma maxilofacial en el Servicio de Urgencias del Hospital Universitario "General Calixto García". 2016-2017 / Maxillofacial Trauma in the Emergency Service of General Calixto García University Hospital. 2016-2017

Introducción: La región maxilofacial es vulnerable a lesiones. En Cuba son escasos los estudios realizados sobre la atención en la urgencia dentro de la traumatología maxilofacial, por lo que surgió la motivación para realizar esta investigación. Objetivo: Caracterizar desde el punto de vista clínico-epidemiológico el trauma maxilofacial en el Servicio de Urgencias del Hospital General Calixto García en el período de junio 2016 a junio 2017. Material y Métodos: Se realizó un estudio descriptivo de corte transversal del universo de pacientes (2412 pacientes) atendidos en el Servicio de Urgencias del Hospital Universitario General Calixto García, desde junio del 2016 a junio del 2017; que tuvieron como diagnóstico trauma maxilofacial. Las variables empleadas fueron: grupos de edad, sexo, factor etiológico, tipo de lesión, conducta terapéutica. Resultados: En el estudio los pacientes con edades comprendidas entre 19 y 30 años representaron 41,0 por ciento; el sexo masculino 69,0 por ciento y los accidentes de tránsito 34,6 por ciento. Las lesiones de tejido duro más frecuentes fueron las fracturas nasales (13,9 por ciento); y de tejidos blandos las heridas puramente tegumentarias (82,1 por ciento). La colocación de vendajes se utilizó en 89,1 por ciento, y la sutura de heridas en 84,1 por ciento. Conclusiones: El comportamiento del trauma maxilofacial en el Servicio de Urgencias del Hospital Universitario General Calixto García, muestra que es predominante en hombres de edad intermedia y debido a accidentes de tránsito. Hay superioridad de lesiones de tejido blando y dentro de estas, de heridas puramente tegumentarias. La conducta conservadora, en su modalidad de colocación de vendaje, es la más empleada(AU)

Introduction: The maxillofacial region is vulnerable to injuries. In Cuba, few studies related to urgent care services have been carried out in maxillofacial traumatology, which led to an increase of motivation to conduct this research. Objective: To characterize maxillofacial trauma from a clinical and epidemiological point of view in patients treated in General Calixto García Hospital from June 2016 to June 2017. Material and Methods: A descriptive cross-sectional study was conducted with the universe of patients (2412 ones) that were treated in the Emergency Service of General Calixto García University Hospital with the diagnosis of maxillofacial trauma from June 2016 to June 2017. The variables used were: age groups, sex, etiological factor, type of injury, and therapeutic behavior. Results: In the study, the patients aged between 19 and 30 years represented 41.0 percent; the male sex 69.0 percent; and the traffic accidents 34.6 percent. The most frequent hard tissue injuries were nasal fractures (13.9 percent); and the soft tissue injuries were purely integumentary wounds (82.1 percent). Bandage placement was used in 89.1 percent, and wound suture in 84.1 percent. Conclusions: The behavior of the maxillofacial trauma in the Emergency Service of General Calixto García University Hospital, showed that it predominates in men of middle age due to traffic accidents. Soft tissue injuries were the predominant type of injuries, among them, the purely integumentary wounds. The conservative behavior in its modality of bandage placement was the most commonly used(AU)

Endoscope-assisted repair of facial bone fractures

Comparison of the Usefulness of MDCT (Multidetective Computed Tomogram) in Facial Bone Fractures

PURPOSE: In maxillofacial surgery, proper preoperative diagnosis is very important in achieving good postoperative results. Although conventional CT scans are useful for visual representations of fractures, they cannot provide direct guidance for reconstructing facial bone fractures. However, the recent technology of multislice scanning has brought many clinical benefits to CT images. Direct correlations can be made between preoperative imaging data and operative planning. The aim of the current study is to evaluate the differences between conventional CT and multidetective three-dimensional CT(3D MDCT) measurements in craniofacial deformities. METHODS: From January 2005 to November 2005, MDCT scans of 41 patients were evaluated by comparing them with conventional CT scans. The 3D MDCT images were assessed and reviewed by using a simple scoring system. RESULTS: The 3D MDCT scans offered easy interpretation, facilitated surgical planning, and clarified postoperative results in malar complex fractures, mandibular fractures, and extensive maxillofacial fractures and cranioplasty. However, 3D MDCT images were not superior to conventional CT scans in the diagnosis of blowout fractures. CONCLUSION: In spite of its limitations, the 3D MDCT provided additional and more comprehensive information than the conventional CT for preoperative assessment of craniofacial deformities. Therefore, the 3D MDCT can be a useful tool for diagnosis and systematic treatment planning in craniofacial skeletal deformities.

Bioabsorbable Skeletal Fixation System Devices in Reduction for Facial Bone Fracture

The rigid metal fixation devices are currently the most widely used in maxillofacial surgery. The use of metal plate and screw fixation, however, is not free of some postoperative complication. Once the fractures have healed, metal devices no longer serve any tissue purpose other than the potential for adverse reaction, including loosening, palpability, corrosion, and artifacts in CT and MRI, and they restrict growth of the neurocranium. To overcome these drawbacks, there had been a continuous research on the development of a bioabsorbable skeletal fixation system using polymers of polylactic and polyglycolic acid. There is an increasing acceptance of there use as an alternative fixation device in craniomaxillofacial surgery. We have used the BiosorbFX(R) system(Bionix Implants Ltd) in 48 patients of facial bone fractures. Age varied from 3 to 70(mean 34) and follow up period varied form 1 months to 10 months(mean 5 months). A total of 860 bioabsorbable devices(151 plates and 709 screws) was used. We encountered no significant intraoperative difficulties in obtaining placement of the devices. No patients has experienced any implant-related complications including infection, fracture instability or relapse, or radiographic evidence of osteolysis. The use of nonmetallic materials as a fixation devices that will be resorbed after facial bone fracture healing, therefore, would have advantages. The good results indicate that the use of bioabsorbable implants can be considered for the fixation of facial bone fractures.

Trocar Application in The Treatment of Various Facial Bone Fractures

The treatment of facial bone fractures aims at restoring normal anatomical feature and obtaining the physiologic function by accurate fracture reduction and adequate stability. Among various facial bone fractures, displaced mandibular angle and subcondylar fractures are common injuries. Their structural problems such as increased risk of oromasticatory dysfunction and aesthetic drawbacks can be corrected by surgical treatment. In case of displaced comminuted fracture of zygoma, the zygomatic arch should be reduced and rigidly fixed, because it can be used as a key landmark for reconstruction. In case of these fractures, we performed external incision and conventional bicoronal incision to repair mandibular fractures and expose zygomatic arch. However, there are some disadvantages associated with these extensive incisions: a possible facial nerve injury, prolonged massive swelling, noticeable external scarring and increased risk of blood loss. On the other hand, the intraoral incision approach for mandibular angle, subcondyle and zygomatic arch makes possible the anatomic reduction and rigid internal fixation by using a trocar method concomitantly, which requires only an additional small skin incision over the perpendicular point of the fracture site. Additionally, this approach has several advantages, including decreased possibility of facial nerve injury, decreased blood loss, early subsidence of postoperative swelling and minimal external scarring. From March 1997 to November 1999, we used the trocar method for the treatment of various facial bone fractures of 15 males and 3 female patients (age ranged from 17 to 60 years). In this approach, operative endoscope or C-arm was used concomitantly in order to improve the limited operative visual field and to allow surgical access. The use of trocar method through the intraoral and tiny skin incisions provides the accurate reduction and rigid internal fixation. It is considered a good method to minimize the disadvantages of external approaches for the treatment of various facial bone fractures.

COMPARISON OF THREE-DIMENSIONAL CT IMAGED WITH CONVENTIONAL CT IMAGES IN THE DIAGNOSIS OF THE FACIAL BONE FRACTURES

Despite advances in radiology -- including CT scanning -- three-dimensional (3D) nature of facial bone fractures must be inferred by the spatial imagination of the physician. Thus, in order to assess the usefulness of 3D-CT, 3D-CT reformations were obtained in 24 patients presenting with facial injuries of differing severity from 7. 1993 to 5. 1995. The 3D images were compared with high resolution CT, including multiplanar reformations, and assessed under the headings of fracture detection, extent and displacement using a single scoring system.3D was valuable in extensive facial fractures, providing a clear demonstration of fracture extent and fragment displacement. 3D was equally useful in the diagnosis of malar complex fractures and mandible fractures. However, 3D was much less useful in the diagnosis of orbital blow-out fractures and minor trauma, in which little or no fragment displacement had occurred, than conventional CT. In conclusion, when used as part of a high resolution CT examination, 3D imaging can provide useful information to surgeon in cases of severe facial trauma.