Gun orientation in self-inflicted craniomaxillofacial gunshot wounds: risk factors associated with fatality.

The purpose of this study was to evaluate whether orientation of a firearm predicts survival, and to identify risk factors associated with fatality in subjects with self-inflicted craniomaxillofacial gunshot wounds. A retrospective cohort study design was used. The primary predictor variable was orientation of the weapon, defined as in the coronal (lateral) or sagittal (anterior-posterior) trajectory pattern. The primary outcome variable was death for subjects on arrival or during their hospital stay. Other covariates measured include demographic, firearm-related, and psychosocial variables. Risk factors for fatality were identified using multivariate logistic regression. Of the 92 subjects that met study inclusion criteria, 47 (67.2) held the firearm in the coronal position. In the full multivariate model, coronal gun orientation (OR=7.7, 95% CI: 2.0, 30.1, p=0.003) and the absence of a psychiatric diagnosis were associated with an increased risk of fatality (OR=0.1, 95% CI: 0.04, 0.5, p=0.002). Coronal firearm orientation was associated with an increased risk of fatality following self-inflicted craniomaxillofacial gunshot injuries. A patient with a documented psychiatric disorder was not found to be more likely to succumb to this type of injury.

Vascularized free tissue transfer for reconstruction of ablative defects in oral and oropharyngeal cancer patients undergoing salvage surgery following concomitant chemoradiation.

The purpose of this study was to determine whether chemotherapy delivered concurrently with external beam radiation therapy for loco-regionally advanced head and neck cancer affects the rate or severity of postoperative complications in patients who underwent salvage surgery for recurrent or persistent disease with simultaneous microvascular free flap reconstruction. The primary study group consisted of patients with head and neck malignancies that had undergone surgical salvage with microvascular free flap reconstruction for persistent or recurrent disease following definitive radiation or concomitant chemoradiation treatment. A group of demographically matched patients who underwent microvascular free flap reconstruction for non-malignant and malignant conditions who never received radiation were randomly selected to serve as a control group. The study cohort was divided according to radiation treatment. The overall success rate of flap reconstruction was 92%, with an overall complication rate of 23%. Concurrently administered chemotherapy did not appear to affect the type of or the complication rate. The results of this investigation indicate that microvascular free flap reconstruction of head and neck defects is highly predictable, results in relatively few major complications, and suggests that neither radiation alone nor concomitant chemoradiation has a statistically significant effect on overall flap survival or complication rate.

Maxillofacial injuries associated with domestic violence.

PURPOSE: The purpose of this study was to report the incidence, causes, and patterns of maxillofacial injury associated with domestic violence. PATIENTS AND METHODS: A retrospective review of patients treated for domestic violence injuries at an inner-city hospital over a 5-year period was done, and data were collected on type and location of injury, mechanism of injury, alcohol involvement, and treatment. RESULTS: The sample consisted of 236 emergency room admissions. The majority (81%) of victims presented with maxillofacial injuries. The fist was a favorite means for assaults (67%). The middle third of the face was most commonly involved (69%). Soft tissue injuries were the most common type of injury (61%). Facial fractures were present in 30% of victims. The average number of mandible fractures per patient was 1.32. The majority of facial fractures (40%) were nasal fractures. Left-sided facial injuries were more common than right sided. CONCLUSIONS: These data confirm that most victims of domestic violence sustain maxillofacial injuries. Midface injuries predominate. The preponderance of facial injuries makes it very likely that oral and maxillofacial surgeons will be involved in the care of these patients.

Segmental resection of the anterior mandibular arch with fibular microvascular reconstruction.

Segmental mandibular resection should be undertaken if there is a demonstrable invasion by cancer or if such invasion is suspected. Before the advent of microvascular free flaps, immediate osseous reconstruction of the anterior mandible was technically demanding and unreliable. Mandibular reconstruction with microvascular free flaps is no longer a novelty, nor is it reserved for unusually large resections. It has become the method of choice for the immediate reconstruction of defects resulting from mandibular cancer. This technique is particularly well-suited for defects of the anterior mandibular arch.

Cementifying fibroma presenting as proptosis.

Cementifying fibromas are rare fibro-osseous tumors that arise from the periodontal ligament. These tumors are usually small, asymptomatic lesions noted on routine dental radiography, but they can develop into aggressive, expansile masses. The authors report the case of a 12-year-old boy with a tumor involving the maxillary, ethmoid, and frontal sinuses that extended to the right orbit, causing proptosis and disfigurement of the right side of his face. Removal of the tumor with facial reconstruction resulted in significant improvement of vision, despite long-standing disc edema and tension on the optic nerve. On histopathologic examination the lesion was found to be a cementifying fibroma.

Creating a practice partnership: a clinical application of case management.

Using the framework of case management, a team partnership was developed for the head and neck surgery population undergoing reconstruction with free tissue transfers ("free flaps"). The focus of the partnership was to improve care coordination from surgery scheduling through discharge. Practice agreements were negotiated, pre-printed on a clinical path, and further supported by pre-printed physician's orders, teaching materials, and a variance tracking tool. In the 6 months since implementing this partnership, patients have recovered more quickly, reducing length of stay by 25% and costs by 15% to 20%.

Management of associated dental injuries in maxillofacial trauma.

Maxillofacial trauma frequently is accompanied by significant injuries to the teeth and their supporting structures. This review of these dental injuries relates their management to other priorities of the head and neck trauma patient. The controversy over management of the tooth within the line of a mandibular fracture is discussed.

Fulminant infections of odontogenic origin.

The dentition is a common source of infection in the head and neck and most odontogenic infections respond uneventfully to proper dental therapy. Some more fulminant odontogenic infections can produce complications including airway obstruction, necrotizing fasciitis, and extension of the infection to the orbits, intracranial structures, and thorax. Six such cases treated by the authors are presented and recommendations for management including aggressive antimicrobial, therapy-based bacteriology and surgical drainage and debridement are made.