Principios y recursos clásicos y modernos: combinación en el manejo de fracturas tipo Le Fort / Classical and modern principles and resources: their combination in the management of Le Fort fractures

Introducción: Las lesiones traumáticas maxilofaciales son un problema de salud importante en todo el mundo. Suponen una carga para la salud pública. Objetivo: Reflexionar sobre la necesidad de combinar en el contexto cubano principios y recursos clásicos y modernos en el manejo de fracturas tipo Le Fort. Comentarios principales: El tratamiento de las fracturas faciales ha evolucionado mucho a lo largo de los años. Tradicionalmente, el alambre de acero inoxidable se utilizaba para la osteosíntesis en cirugía maxilofacial hasta la aparición de las miniplacas. Los sistemas de osteosíntesis de titanio son actualmente los de elección en cirugía maxilofacial. A pesar de sus ventajas indiscutibles, en los países en desarrollo ocasionalmente no se cuenta con todo el equipamiento necesario para su empleo. Consideraciones globales: El manejo del trauma maxilofacial se centra en la reobtención de la forma y la función original de la región afectada. Sin vulnerar los principios teóricos de manejo de fracturas tipo Le Fort, se impone de los profesionales cubanos la búsqueda de soluciones en concordancia con la disponibilidad de recursos. La unión de técnicas clásicas y recursos modernos como las suspensiones craneofaciales alámbricas, los arcos barra y los tornillos de fijación maxilomandibular puede ser una alternativa terapéutica confiable(AU)

Introduction: Traumatic maxillofacial lesions are an important global health problem, as well as a public health burden. Objective: Reflect on the need to combine classical and modern principles and resources in the management of Le Fort fractures in the Cuban context. Main remarks: Treatment of facial fractures has evolved considerably through the years. Before the appearance of miniplates, stainless steel wire was used for osteosynthesis in maxillofacial surgery. Titanium osteosynthesis systems are currently the systems of choice in maxillofacial surgery. Despite their undeniable advantages, developing countries occasionally do not have all the equipment required for their use. General considerations: Management of maxillofacial trauma is aimed at recovering the original form and function of the affected area. Without disregarding the theoretical principles of the management of Le Fort fractures, Cuban professionals should search for solutions in keeping with the resources available. The combination of classical techniques and modern resources, such as wired craniofacial suspensions, bar arches and maxillomandibular fixation screws, may be a reliable therapeutic alternative(AU)

Temporomandibular joint function 10-15 years after mandibular setback surgery and six weeks of intermaxillary fixation

Abstract Intermaxillary fixation (IMF) is a classic method for immobilization of the mandible after mandibular fractures and corrective surgery. However, it has been suggested that IMF may be a risk for developing temporomandibular joint (TMJ)-related symptoms, especially when applied for longer periods. Objective: To evaluate the clinical function of TMJs and masticatory muscles 10-15 years after mandibular setback surgery and subsequent six weeks of IMF. The patients' self-reported TMJ and masticatory muscle symptoms were also addressed. Methodology: Thirty-six patients (24 women and 12 men) treated with intraoral vertical ramus osteotomies and subsequent six weeks of IMF, underwent a clinical examination of TMJs and masticatory muscles 10-15 years after surgery and completed a five-item structured questionnaire reporting subjective TMJ-related symptoms. Mean age by the time of clinical examination was 34.1 years (range 27.2-59.8 years). The clinical outcome was registered according to the Helkimo clinical dysfunction index. Descriptive and bivariate statistics were performed and level of significance was set to 5%. Results: Mean maximum unassisted mouth opening 10-15 years after surgery was 50.1 mm, (range 38-70 mm, SE 1.2), statistically significantly greater in men compared to women (p=0.004). Mean Helkimo dysfunction group was 1.5 (range 1-3, SE 0.10). Eighty-one percent experienced pain on palpation in either the masseter muscle, temporal muscle or both, and 31% experienced pain when moving the mandible in one or more directions. Thirty-one percent reported pain from palpating the TMJs. In the questionnaire, none reported to have pain during chewing or mouth opening on a weekly or daily basis, but 22% reported difficulties with maximum opening of the mouth. Conclusion: Ten to fifteen years after mandibular setback surgery the patient's mandibular range of movement is good. Despite clinically recognizable symptoms, few patients reported having TMJ- or masticatory muscle-related symptoms in their daily life.

Fracturas del tercio medio facial / Midface fractures

Introducción: las fracturas del tercio medio facial plantean un problema médico grave en cuanto a su complejidad, frecuencia e impacto socioeconómico. Objetivo: realizar una revisión bibliográfica sobre sus consideraciones anatómicas, diagnóstico, clasificación, tratamiento y complicaciones de las fracturas del tercio medio facial. Métodos: se realizó una revisión bibliográfica en septiembre de 2016. Se evaluaron revistas de impacto de Web of Sciencies (25 revistas) y 2 libros. Se consultaron las bases de datos de MEDLINE, PubMed y ScieELO con los descriptores: maxillary fracture, treatment, lefort fracture. Se incluyeron artículos en idioma inglés, de los últimos 5 años. Se obtuvieron 98 artículos. El estudio se circunscribió a 40. Análisis e integración de la información: el tercio medio muestra debilidad anatómica al estar formado por huesos esponjosos, con múltiples suturas y poco protegidos. Existen múltiples clasificaciones de estas fracturas y el diagnóstico se basa en los hallazgos clínicos, siendo de importancia los oftalmológicos, que unidos a los de los medios auxiliares de diagnóstico, permiten escoger la modalidad terapéutica y evitar complicaciones. Conclusiones: las características anatómicas del tercio medio facial justifican la frecuencia y su repercusión de estas fracturas. El diagnóstico debe basarse en el interrogatorio, examen físico y los medios auxiliares de diagnóstico imaginológicos, fundamentalmente tomográficos. Al clasificar la fractura se puede establecer un plan de tratamiento basado en la valoración individual de cada caso con el objetivo de evitar complicaciones posteriores(AU)

Introduction: midface fractures are a serious medical problem due to their complexity, frequency and socioeconomic impact. Objective: conduct a literature review about the anatomical considerations, diagnosis, classification, treatment and complications of midface fractures. Methods: A literature review was conducted in September 2016. The evaluation included high impact journals from the Web of Science (25 journals) and 2 books. The databases MEDLINE, PubMed and SciELO were consulted, using the descriptors maxillary fracture, treatment, lefort fracture. Papers written in English in the last five years were included. Of the 98 papers obtained, the study considered 40. Data analysis and integration: the middle third of the face is characterized by anatomical weakness, since it is formed by scantily protected spongy bone with multiple sutures. There are many classifications for midface fractures, and diagnosis is based on clinical findings, particularly ophthalmological, which alongside those of auxiliary diagnostic devices, make it possible to choose the most appropriate therapeutic mode and prevent complications. Conclusions: the anatomical characteristics of the facial middle third justify the frequency and impact of these fractures. Diagnosis should be based on interrogation, physical examination and the use of auxiliary diagnostic imaging, mainly tomography. Upon classification of the fracture, a treatment plan may be devised based on individual assessment of each case to prevent future complications(AU)

Fractura condílea / Condylar fracture

Introducción: el cóndilo representa un punto estructural débil en el esqueleto mandibular. Objetivo: realizar una revisión bibliográfica sobre consideraciones anatómicas, diagnóstico, clasificación, tratamiento y complicaciones de las fracturas condíleas. Métodos: se realizó una revisión bibliográfica en agosto de 2016. Se evaluaron revistas de impacto de Web of Sciencies (17 revistas), 2 libros y 1 CD. Se consultaron las bases de datos MEDLINE, PubMed y SciELO con los descriptores: condilar fracture, treatment, epidemiology. Se incluyeron artículos en idioma inglés, preferentemente de los últimos 5 años. Se obtuvieron 111 artículos. El estudio se circunscribió a 34. Análisis e integración de la información: las consideraciones anatómicas de la región condílea son un punto de partida en este tema. El diagnóstico se basa en el interrogatorio, examen físico y medios auxiliares de diagnóstico. La clasificación precisa permite escoger la modalidad terapéutica a emplear y evitar complicaciones. Conclusiones: la revisión de la bibliografía permite precisar que hay razones anatómicas para la alta incidencia de las fracturas del proceso condilar mandibular. El primer objetivo del interrogatorio es obtener una historia exacta del paciente. El examen físico regional debe ser exhaustivo. La radiografía panorámica es una buena opción en el diagnóstico. El primer paso en el desarrollo de un plan de tratamiento es establecer qué tipo de lesión se ha sufrido para proporcionar una solución adecuada usando técnicas abiertas y cerradas, y evitar complicaciones posteriores(AU)

Introduction: the condyle represents a weak structural point in the mandibular skeleton. Objective: to perform a bibliographic review on anatomical considerations, diagnosis, classification, treatment and complications of condylar fractures. Methods: abibliographic review was carried out in August 2016. Journals of impact in the Web of Sciences (17 journals), 2 books and 1 CD were evaluated. The databases MedLine, PubMed and ScieELO were consulted with the descriptors: condylar fracture, treatment, and epidemiology. Articles in English were included, preferably from the last 5 years. 111 articles were obtained. The study was circumscribed to 34. Analysis and integration of information: the anatomical considerations of the condylar region are a starting point in this topic. The diagnosis is based on the interrogation, physical examination and diagnostic aids. Accurate classification allows choosing the therapeutic modality to be used and avoiding complications. Conclusions: the review of the literature makes it possible to specify that there are anatomical reasons for the high incidence of fractures of the mandibular condylar process. The first objective of the interrogation is to obtain an accurate history of the patient. The regional physical examination must be comprehensive. The panoramic radiograph is a good option for the diagnosis. The first step in the development of a treatment plan is to establish what type of injury has been suffered, in order to provide an adequate solution using open and closed techniques and avoid later complications(AU)

Fractura mandibular / Mandibular fracture

Introducción: las fracturas mandibulares son frecuentemente atendidas en cirugía bucal y maxilofacial. Objetivo: realizar una revisión bibliográfica sobre consideraciones anatómicas, diagnóstico, clasificación, tratamiento y complicaciones de las fracturas mandibulares. Métodos: se realizó una revisión bibliográfica de julio a agosto de 2016. Se evaluaron revistas de impacto de Web of Sciencies (35 revistas) y 3 libros. Se consultaron las bases de datos de MEDLINE, PubMed y ScieELO con los descriptores: mandibular fracture, treatment, epidemiology. Se incluyeron artículos en idioma inglés, preferentemente de los últimos 5 años. Se obtuvieron 120 artículos. El estudio se circunscribió a 51. Análisis e integración de la información: las consideraciones anatómicas de la región mandibular son un punto de partida en este tema. El diagnóstico se basa en el interrogatorio, examen físico y medios auxiliares de diagnóstico. La clasificación precisa permite escoger la modalidad terapéutica a emplear y evitar complicaciones. Conclusiones: la revisión de la bibliografía permite precisar que hay razones anatómicas para la alta incidencia de las fracturas de ángulo mandibular. El primer objetivo del interrogatorio es obtener una historia exacta del paciente. El examen físico regional debe realizarse de forma ordenada y precisa. La radiografía panorámica es una buena opción en el diagnóstico. El primer paso en el desarrollo de un plan de tratamiento es establecer qué tipo de lesión se ha sufrido para proporcionar una solución adecuada usando técnicas abiertas y cerradas, y evitar complicaciones posteriores(AU)

Introduction: mandibular fractures are often treated by oral and maxillofacial surgery. Objective: conduct a bibliographic review about the anatomical considerations, diagnosis, classification, treatment and complications of mandibular fractures. Methods: a bibliographic review was conducted from July to August 2016. The evaluation included high impact journals from the Web of Sciences (35 journals) and 3 books. The databases MEDLINE, PubMed and SciELO were consulted, using the descriptors mandibular fracture, treatment, epidemiology. Papers written in English were included, preferably if published in the last five years. Of the 120 papers obtained, the study considered 51. Data analysis and integration: anatomical considerations about the mandibular region are a starting point in this topic. Diagnosis is based on interrogation, physical examination and auxiliary diagnostic means. An accurate classification makes it possible to choose the therapy to be used and prevent complications. Conclusions: the bibliographic review permitted to confirm that there exist anatomical reasons for the high incidence of mandibular angle fractures. The first goal of interrogation is to obtain an exact patient history. The regional physical examination should be performed in an orderly, accurate manner. Panoramic radiography is a good choice of diagnostic technique. The first step in developing a treatment plan is to determine the type of lesion so as to provide an appropriate solution based on open and closed techniques, thus avoiding later complications(AU)

TMJ response to mandibular advancement surgery: an overview of risk factors

Objective: In order to understand the conflicting information on temporomandibular joint (TMJ) pathophysiologic responses after mandibular advancement surgery, an overview of the literature was proposed with a focus on certain risk factors. Methods: A literature search was carried out in the Cochrane, PubMed, Scopus and Web of Science databases in the period from January 1980 through March 2013. Various combinations of keywords related to TMJ changes [disc displacement, arthralgia, condylar resorption (CR)] and aspects of surgical intervention (fixation technique, amount of advancement) were used. A hand search of these papers was also carried out to identify additional articles. Results: A total of 148 articles were considered for this overview and, although methodological troubles were common, this review identified relevant findings which the practitioner can take into consideration during treatment planning: 1- Surgery was unable to influence TMJ with preexisting displaced disc and crepitus; 2- Clicking and arthralgia were not predictable after surgery, although there was greater likelihood of improvement rather than deterioration; 3- The amount of mandibular advancement and counterclockwise rotation, and the rigidity of the fixation technique seemed to influence TMJ position and health; 4- The risk of CR increased, especially in identified high-risk cases. Conclusions: Young adult females with mandibular retrognathism and increased mandibular plane angle are susceptible to painful TMJ, and are subject to less improvement after surgery and prone to CR. Furthermore, thorough evidenced-based studies are required to understand the response of the TMJ after mandibular advancement surgery. .

Distracción ósea mandibular: presentación de un caso / Osteomandibular distraction: a case report

Se muestra el avance obtenido en la técnica de distracción ósea en el Hospital Clínicoquirúrgico "Manuel Fajardo" mediante la presentación de un caso. Se analiza esta experiencia tomando como patrón los trabajos de los Dres. Chender, Molina y Guerrero, los cuales han contribuido y colaborado en la aplicación y desarrollo de esta novedosa técnica de elongación ósea. El paciente atendido por este método padecía de retrucción mandibular y en él se utilizó la fijación maxilo-mandibular después de retirado el distractor para garantizar la formación del callo óseo. Se señala que Ortiz Monasterio y Molina, en una serie de 106 casos, no observaron recidivas en su seguimiento de 3 años(AU)

The osteogenic distraction is a method used for bone lengthening by applying a distraction apparatus. Described and used by Dr. Codevilla in the first years (1905) of the XX century, this method was later (1950) developed by Dr. Llizarov in the field of Orthopedics and Traumatology. In the specialty of Maxillofacial Surgery, It became something very novel for the correction of the maxillomandibular development abnormalities, since according to what is estipulated the bone will be lengthened from 1 to 2 mm daily, so the correction of a mandibular retrusion of 15 mm will take between 7 and 15 days, according to the times the distractor's rod is turned. The advance attained with this technique at "Comandante Manuel Fajardo" Clinical and Surgical Hospital is shown through the report of a case, and this experience is analyzed taking as a reference the work done by Dr. Chender, Dr. Molina and Dr. Guerrero, who have contributed to and collaborated with the application and development of this new technique of bone lengthening. The patient treated by this method suffered from mandibular retrusion. In this patient, the maxillomandibular fixation was used after removing the distractor to guarantee the formation of the bony callus. It was stressed that Ortiz Monasterio and Molina did not observe relapses in a series of 106 cases in a 3-year follow-up(AU)