Complex-type penetrating injuries of craniomaxillofacial region.

Craniofacial traumas are one of the most common clinical events of the 21st century. The possibility of associated injuries of the head and neck may also determine functional and cosmetic problems in these patients. The most frequent pathologic conditions observed are contusions, lacerations, abrasions, avulsions, and the inclusion of foreign bodies. In particular, penetrating injuries represent a rare but complex variety of craniofacial trauma. Generally, the penetrating material is stiff enough to cross through different anatomic structures during a particularly violent collision caused by a road or work accident or during an attack. The therapeutic strategy adopted for this type of patient depends mainly on diagnostic procedures such as skull radiograms in different projections, computerized tomography, magnetic resonance imaging, and, occasionally, echotomography. However, on arrival at the emergency department, the clinical conditions of the patient will determine the type of investigation to be carried out. Last, to prevent any postoperative infections, wide spectrum antibiotic therapy is advisable. Ideally, imaging should be repeated postoperatively to confirm resolution of the initial clinical condition. In this article, the authors describe three unusual clinical cases of patients with penetrating injuries of the head and face together with the protocol adopted for treatment of such complex craniofacial injuries. The three cases described demonstrate that, despite the initial appearance of penetrating wounds, a correct diagnostic assessment followed by a suitable therapeutic protocol can reduce cosmetic and functional defects to a minimum.

Variations of the gonial angle in vertical surgical reduction of the maxillary-mandibular complex.

From an esthetic point of view, the mandibular or gonial angle plays an important role in ensuring a harmonious facial profile. The purpose of this study was to analyze the values of the mandibular angle in relation to variations of the vertical and sagittal positions of the jaw. The study was carried out on a sample of 42 patients who underwent surgery for maxillary-mandibular repositioning, advancing or raising the jaw, after a Le Fort I osteotomy and bilateral sagittal osteotomy of the jaw according to the technique described by Obwegeser-Dal Pont. In all patients, the maxillary bone was raised with a discrepancy of at least 3 mm between the anterior and posterior portions (favoring the latter) as a result of (clockwise) rotation of the bispinal plane. The data, obtained by means of cephalometric analysis according to the method of Ricketts, showed how changes in the gonial angle differed between patients who require correction of an open-bite and those who do not. In particular, in patients without an open-bite, advancement of the maxilla limited the opening of the angle. Similarly, in patients with an open-bite, the tendency to form an open gonial angle can usually be corrected by the association of advancement of the maxilla whenever possible.

Combined surgical therapy of temporomandibular joint ankylosis and secondary deformity using intraoral distraction.

Temporomandibular joint (TMJ) ankylosis is a pathological process caused by damage of the mandibular condyle. When this event takes place in subjects during the developmental age, it results in an alteration of the entire maxillofacial complex. Therefore, surgical methods able to remove the temporomandibular ankylosis also include necessary operations to correct the secondary maxillofacial deformity. The distraction osteogenesis has induced our center to modify the surgical protocol for the therapy of patients who have developed TMJ ankylosis and secondary maxillomandibular deformity. We have treated four patients with monolateral ankylosis of the TMJ and serious deformities of the maxillomandibular complex secondary to functional limitation. During the same operation, arthroplasty was performed with the removal of the ankylotic block and the interposition of a temporal muscle flap in the new articular space; an intraoral osteodistractor was also positioned to lengthen the mandible. All patients showed recovery of the eurhythmy of the face and good re-establishment of the symmetry. An average 12-month follow-up showed the average opening of the mouth to be at least 35 mm. The combination of TMJ arthroplasty and intraoral osteodistraction provides good functional and aesthetic results in patients affected by ankylosis who have developed secondary maxillofacial deformities.