A comprehensive classification of mandibular fractures: a preliminary agreement validation study.

This study evaluates a comprehensive classification system for mandibular fractures based on imaging analysis. The AO/ASIF scheme, defining three fracture types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest) was used. The mandible is divided into two vertical units (I and V), two lateral horizontal units (II and IV) and one central unit (III) comprising the symphyseal and parasymphyseal region. Type A fractures are non-displaced, type B are displaced and type C are multifragmentary/defect injuries. Groups and subgroups are further defined in the classification system. Two classification sessions using semi-automatic software with 7 and 9 surgeons were performed to evaluate 100 fracture cases in the first session and 50 in the second. Inter-observer reliability and individual rater's accuracy were evaluated by kappa coefficient and latent class analysis, respectively. The analysis of inter-observer agreement for the detailed coding showed kappa coefficients around 0.50 with higher agreement among raters in the vertical units. This system allows standardization of documentation of mandibular fractures, although improvement in the definition of categories and their application is required.

Lip and perioral defects.

Reconstruction of the lip and perioral region presents a myriad of problems, as deformities of this region can produce both aesthetic deformation and functional difficulties. This article reviews basic principles of lip reconstruction, emphasizing the differences between defects of the upper and lower lip.

Management of aggressive midface and orbital fibrous dysplasia.

OBJECTIVE: To discuss cosmetic and functional implications in the evaluation and treatment planning of large, aggressive midfacial fibrous dysplasias. PATIENTS AND METHODS: Eight patients (aged 2-38 years) with large fibrous dysplasias of the maxilla, zygomatic, and ethmoid bones requiring varying degrees of intervention and reconstruction were retrospectively reviewed. Patients with smaller lesions of these regions not requiring resection and reconstruction, as well those requiring sinus surgery alone were excluded from this review. RESULTS: All fibrous dysplasias in this review were monostotic, 6 originating in the maxilla, 1 in the zygoma, and 1 in the ethmoid. Five lesions (4 maxillary, 1 zygomatic) caused cosmetic deformity without functional deficits and required resection and/or contouring only with minimal reconstruction. The remaining lesions were invasive such that function of the eye and/or dentition was affected. These lesions were treated by aggressive resection and various degrees of reconstruction to optimize function. CONCLUSIONS: While fibrous dyplasia is classified as a benign process, local expansion can cause significant functional and aesthetic deformities. Each lesion should be thoroughly evaluated and, when vital structures are involved or threatened, total or subtotal resection should be considered. A variety of options should be available to the surgeon for definitive primary reconstruction.

Midface fractures.

Fractures of the middle portion of the facial skeleton are commonly referred to as midface or LeFort fractures. While significant progress has been made in terms of evaluation and treatment of such fractures, they remain a challenge for the maxillofacial surgeon. In this section, we will review the principles of midface fracture evaluation and repair, emphasizing the importance of understanding biomechanics and controversies that exist in respect to repair sequencing.

Optimal elective scalp incision design.

Scalp incisions of an elective nature are commonly used as an approach in upper cranial maxillofacial surgery. Similarly, isolated linear parietal incisions are occasionally used to harvest outer table calvarial bone grafts. Although morbidity from these incisions is generally minimal, there is a tendency, particularly when a scar is widened, for it to be more visible if it is of a linear nature. In this review we will present our results with 16 consecutive patients in which a geometric pattern incision was used instead of a straight incision in hopes of improving the ultimate appearance of this scar. We have found that, in general, incisions made in a geometric fashion are less noticeable than traditional linear elective scalp incisions. This is particularly true when there was widening of the scar.

Calvarial bone graft harvest in children.

Bone grafts are occasionally required in the reconstruction of bony defects in the pediatric population. Strong recommendations have existed in the past toward the use of principally inner table bone grafts in children. In this retrospective series with an upper age limit of 14 years, outer table calvarial bone grafts were used as the material of choice for bony reconstructions. There were no complications relative to the outer table graft harvest in any of these 12 patients. Discussion of harvest techniques in different pediatric age groups will be reviewed.

Facial suspension with acellular human dermal allograft.

OBJECTIVE: To study the efficacy of acellular human dermal (AHD) allograft as a material for static slings used to treat ptosis of the oral commissure after facial paralysis. DESIGN: In the university facial plastic surgery practices (Baltimore, Md, and Albuquerque, NM) of the senior author (J.L.F.), 11 consecutive patients with facial paralysis were treated with AHD allograft slings. Follow-up was 4 to 14 months with 1 patient excluded for inadequate follow-up. Six of the remaining 10 patients received radiation therapy. Results were considered excellent and designated grade 1 when the affected oral commissure was at the same level as the normal commissure. Complete ptosis was designated grade 4. Grades 2 and 3 were designated between these extremes. RESULTS: All 10 patients showed improvement in the position of the oral commissure, in oral competence, and in cheek ptosis. Four patients were grade 1; 5, grade 2; and 1, grade 3. There were no implant extrusions or infections. CONCLUSIONS: The increased biointegration of AHD allografts in comparison with alloplastic materials may account for the absence of infection reported in this study and the relatively high success rate, especially in patients receiving radiation therapy.

Treatment of occipital acne keloidalis by excision followed by secondary intention healing.

OBJECTIVE: To demonstrate the principle of excision with healing by secondary intention in the treatment of occipital acne keloidalis, a chronic, inflammatory condition characterized by inflammation and hypertrophic scarring on the posterior aspect of the neck and the occipital aspect of the scalp. SETTING: Academic teaching institution. METHODS: Five consecutive patients with massive (> 10 x 15-cm) occipital keloids, all actively infected and growing, were treated by excision of the lesion deep to the dermis and hair follicles. Aggressive local wound care of the wound followed, with the end point being complete reepithelialization of the region. RESULTS: Complete wound closure took place in all patients within 6 to 10 weeks. No complications or recurrences occurred. Cosmetic results were judged as fair to good. Follow-up ranged from 2 months to 4 years. CONCLUSIONS: Successful treatment of occipital acne keloidalis with direct excision and secondary intention wound healing is demonstrated. While cosmetic results are not optimal, this form of treatment has produced stable scar beds without return of infection or keloids.

The use of bone grafts in the upper craniomaxillofacial skeleton.

While a plethora of new biologic and alloplastic materials are available for reconstruction of defects in the upper craniomaxillofacial skeleton, the role of free non-vascularized bone grafts remains an important one. In this review, this role will be defined in detail using case presentations to demonstrate a variety of ways in which such bone grafts may be helpful in reconstructing various facial skeletal defects.

The use of intraoperative image-guided surgical techniques for reconstruction of orbital and zygomatic deformities.

Secondary orbital and periorbital skeletal reconstruction remains a difficult challenge. Recent use of intraoperative CT image guided surgery techniques have allowed an improved operator confidence in such reconstructions. In this review, cases illustrating the use of image guided surgery techniques in patients with fixed, secondary orbital and zygomatic deformities will be demonstrated.

The use of high-density polyethylene implants in facial deformities.

OBJECTIVE: To determine the usefulness of porous high-density polyethylene implants (Medpor) in a variety of facial skeletal deformities and subcutaneous defects, excluding those associated with acute maxillofacial trauma. DESIGN: Case series. SETTING: Academic tertiary care referral center in Baltimore, Md. PATIENTS: Thirty-four patients (age range, 20-74 years) with facial deformities requiring skeletal defect reconstruction or augmentation (38 cases), treated between January 1, 1992, and January 1, 1997. Follow-up ranged from 6 months to 40 months. MAIN OUTCOME MEASURES: Age, type and origin of the deformity treated, type of treatment, and complications. RESULTS: Types of deformities and defects treated include 7 patients with orbital defects (secondary traumatic or oncologic deformities), 8 with temporal fossa defects, 8 with frontocranial defects, 4 with maxillary or malar defects, 7 with calvarial bone graft donor site defects, 2 with microtia, and 2 with chin deficiency. Forty implants were placed. Complications included implant exposure in 4 patients and inappropriate augmentation in 1 patient (chin implantation). CONCLUSIONS: High-density polyethylene implants offer an excellent alternative to autogenous and other alloplastic materials in reconstruction of many facial defects and deformities. Advantages include its versatility and relatively ideal pore size that allows for excellent soft tissue ingrowth and coverage. Disadvantages include its rigid nature and difficulty in contouring to the surface of complex skeletal structures.

Secondary reconstruction of upper midface and orbit after total maxillectomy.

OBJECTIVE: To evaluate the aesthetic and functional results of secondary reconstruction of the upper midface and lower orbit following globe-sparing maxillectomy. DESIGN: Retrospective analysis. SETTING: University medical center. PATIENTS: Six patients, all having previously undergone globe-sparing maxillectomies with or without postoperative radiotherapy, were selected for secondary reconstruction of the upper midface. INTERVENTION: Free calvarial bone grafts (CBGs) alone or in conjunction with alloplastic material were used to reconstruct the upper midface and lower orbit both aesthetically and functionally. Bone grafts were secured using lag screw and nonrigid techniques. Pedicled temporoparietal fascia (TPF) flaps provided coverage of the reconstructions and internal lining of the maxillectomy cavity. OUTCOME MEASURES: Aesthetic and functional results of upper midface and lower orbit as determined by preoperative and postoperative photographs and physical examination. RESULTS: All patients had considerable improvement in upper midfacial contours. All patients had improvement of globe position. Patients with diplopia before reconstruction noted improvement after reconstruction, although 1 patient continued to have moderate diplopia. Complications included persistent globe malposition, persistent diplopia, bone graft resorption, partial loss of 1 TPF flap, need for revision surgery, and subjectively worsened appearance in 1 patient. CONCLUSIONS: Reconstruction with CBGs, alloplastic material, and TPF may reliably, effectively, and efficiently rehabilitate the functional and aesthetic upper midfacial deficits of select patients with secondary reconstruction after globe-sparing maxillectomy. However, patients with evidence of excessive scarring may benefit more from free-tissue transfer reconstruction.

Functional dental rehabilitation of massive palatomaxillary defects: cases requiring free tissue transfer and osseointegrated implants.

BACKGROUND: Mandibular reconstruction with functional dental rehabilitation using a free tissue transfer bone flap as the substrate for osseointegrated implant-borne or implant-retained dental prostheses is well described. Similar use of these techniques in maxillary dental rehabilitation is less frequent and has received less attention in the literature. However, in selected cases of extensive composite defects of the maxilla, free tissue transfer reconstruction of the maxillary arch and the use of implant-borne or implant-retained dental prostheses is the only satisfactory method of achieving functional dental rehabilitation. METHODS: Three cases of maxillary reconstruction and dental rehabilitation using free tissue transfer with implant-borne or implant-retained prostheses are presented. Patient selection, reconstructive technique, and the biomechanical considerations in maxillary dental rehabilitation of large palatomaxillary defects are presented. RESULTS: The patients in this report were restored to full maxillary dental functioning. One implant of 17 implants placed in free flap bone was lost due to failure of osseointegration; 94% of the implants placed are stable an average of 18 months after dental rehabilitation was complete. CONCLUSIONS: In selected patients with extensive palatomaxillary defects due to ablative surgery or trauma, the use of free tissue transfer and osseointegrated implant-borne or implant-retained dentures may be the only method possible to restore maxillary dental function. Dental rehabilitation of large maxillary defects presents a number of biomechanical challenges which must be clearly understood and overcome to achieve a long-term, functional dental rehabilitation.

Frontobasilar blast injuries: access and treatment.

Blast injuries involving the frontobasilar region and orbit can present difficult evaluation and treatment challenges. This article presents the surgical treatment of four patients presenting with blast-type injuries involving the central periorbital region and anterior skull base. Three of these were the result of close-range gunshot wounds, and one was caused by an avulsive penetrating tree branch injury during a motor vehicle accident. All four patients underwent frontal craniotomy for exposure to repair significant intracranial injuries. Following intracranial repair of dural and brain injuries, anterior cranial fossa reconstruction was performed. In two of these patients, elective supraorbital osteotomies were performed to allow improved access to the posterior aspect of the anterior skull base. The healing period of all four patients has been without complications relative to the anterior fossa injuries.

Facial soft tissue resuspension following upper facial skeletal reconstruction.

Only recently has the importance of precise soft tissue repositioning to extend access to the cranio-maxillofacial skeleton been appreciated. The authors examined 39 patients who underwent procedures requiring a combination of coronal, lower lid, and buccal sulcus incisions to provide maximal skeletal exposure of the periorbital, zygoma, and maxillary regions; the patients were examined both prior to and following the use of soft tissue resuspension techniques. In this article, the authors demonstrate the need for soft tissue resuspension in procedures of the upper facial skeleton when large areas of soft tissue have been mobilized for the purpose of exposure. They suggest a difference in soft tissue positioning following the degloving approaches to the upper facial skeletal area when intentional soft tissue resuspension is undertaken.

Comparison of implant materials used in maxillofacial rigid internal fixation.

The concept of using metal plates for the alteration or repair of the craniomaxillofacial (CMF) skeleton is based on the ability to mimic the support and protective functions of bone, either temporarily or permanently, with minimal effect on bone healing, remodeling, and growth while avoiding toxicity to surrounding and distant tissues. Plating systems currently available for CMF rigid internal fixation are made from stainless steel, cobalt-chromium alloys, and titanium alloys. Each material exhibits the basic biomechanical and biocompatibility requirements to be acceptable clinically, but there are subtle and significant differences that may influence the choice of one material over another for a given clinical situation. This article reviews concepts of strength, corrosion resistance, biocompatibility, adverse reactions, and imaging characteristics for all three plating materials in addition to how these factors influence clinical choices.