Traumatic dislocation of the mandibular condyle into the middle cranial fossa treated by an intraoral approach.

Dislocation of the mandibular condyle is one of several consequences of facial trauma that can be anticipated. The condylar neck is inherently weak and likely to fracture at the time of impact before dislocating into the middle cranial fossa. A review of the literature revealed that most cases of dislocation of the mandibular condyle into the middle cranial fossa are treated by open reduction and internal fixation via an extraoral approach or are treated conservatively with closed reduction. An intraoral approach is rare. Here we present a patient with traumatic dislocation of the mandibular condyle into the middle cranial fossa who was treated successfully by condylectomy and coronoidectomy through an intraoral approach and intermaxillary fixation followed by mouth-opening exercises and rehabilitation. Stable occlusion and movement of the mandible was achieved and the long-term results have been good. The intraoral approach may be an option in patients with traumatic dislocation of the mandibular condyle into the middle cranial fossa.

The Use of Computer-Aided Design and Manufacturing in Acute Mandibular Trauma Reconstruction.

PURPOSE: Virtual surgical planning (VSP) with subsequent computer-aided design and manufacturing have proved efficacious in improving the efficiency and outcomes of a plethora of surgical modalities, including mandibular reconstruction and orthognathic surgery. PATIENTS AND METHODS: Five patients underwent complex mandibular reconstruction after traumatic injury using VSP from July 2016 to August 2017 at our institution. The Johns Hopkins University Hospital institutional review board approved the present study. The patient's occlusion was restored virtually, and a milled 2.0-mm plate was created that would bridge the defect with the patient in occlusion. RESULTS: Appropriate occlusion was confirmed using postoperative computed tomography. No patient developed any adverse outcomes, except for a minor dehiscence of the intraoral incision in 1 patient that was treated with local wound care. The average interval from the injury to custom plate availability was approximately 7 days. CONCLUSIONS: The utility of this technology in acute complex mandibular trauma can overcome the challenges of traditional treatment. Custom patient-specific prebent and milled plates permit the use of a lower profile and therefore less palpable hardware, can guide reduction, avoid the need for plate bending, and obviate the need for an extraoral incision.

Electric Saw Face Self-Mutilation in a 22-Year-Old Schizophrenic Man: Case Report.

Schizophrenia is a debilitating psychiatric disorder that affects a large segment of the population. It is managed mainly through pharmacotherapy, and family engagement is mandatory in the process. We present a case of self-mutilation in a 22-year-old man who cut his mandible with an electric saw, trying to modify his chin to better his appearance.

A Patient With Severe Lower Face Degloving Injury.

Avulsions of mandible are among the most devastating lesions observed in cranio-maxillofacial traumas. They present an important health problem because of the high risk of morbidity related to deformities that cause functional limitations and esthetic changes. The avulsions commonly result from high-energy effects, which cause complete or partial separation of the mandibular bone of the face. As a result of the intense aggression, the skin and subcutaneous tissues of the bone are usually removed, affecting muscles, fascia, blood vessels, and the surrounding nerves. This article aimed to present a case of partial avulsion of mandible caused by car accident. Here, we emphasize the importance of correctly performing patient stabilization and maintenance of the airways, damage control, and facial reconstruction. Finally, we proceeded with a literature review to discuss standard protocols and controversies in the treatment of these lesions.

Mandibular Nonvascularized Bone Grafts of Critical Sizes and Complex Warfare Defects With Interrami Intraoral Fixation.

The reconstruction of mandibular bone grafts of critical size complex defects and posterior segments malpositioned due to modern warfare injuries is a difficult, challenging task. The condition becomes even more complex if primary reconstruction is carried out inexpertly, which leads to severe disfigurement, rami mesial superior shift, tongue prolapsed, loss of speech, etc.A new interrami intraoral Kirschner wire fixation (IRIF) technique is presented for the reconstruction of large mandibular defects by nonvascularized iliac bone grafts. Twelve symphysis, parasymphysis, and lateral mandibular avulsed or chopped off with bone loss ranging from 5 cm to "ear-to-ear" rami defects underwent nonvascularized iliac bone block graft. A direct stainless steel wire fixation was carried out between bone blocks and original bone. Indirect rigid fixations were applied using a 2-mm horseshoe-shaped K-wire IRIF technique. Two complications were reported: one due to infection and the other due to the mucosa dehiscing where 2 cm of sequestrated bone was removed. The biomechanics (stress/strain distribution and strength) along the K-wire substitute the tension on the alveolar part of the mandible, creating a zone of resistance in the rami zone. This successful bone healing between the mandibular bone and the graft may have resulted from prolonged periods of sufficient stabilization during function of the mandible and bone graft function as one mandible unit during the healing period by IRIF. This new technique is quick, cheap, easy, and well tolerated by the patient for many months without complications and has been successful in modern warfare reconstructions of mandibular bone graft large defects.

An underestimated "ghost" foreign body as an unusual cause of mandibular osseocutaneous fistula formation: impacted spike of a soccer cleat.

In this article, the case of a patient with osteocutaneous fistula at the left malar region secondary to impacted spike of a soccer cleat to the mandible is presented. Both the clinical and radiologic diagnoses failed because of an obscure anamnesis of the patient and the unavailability of viewing the spike in orthopantomogram and computed tomography. Surgical extirpation was performed to the 41-year-old man who was injured in a football match 3 months before the presentation and had a swooning history after an accidental booting. There were no early or late complications after the surgery at the end of 9 months. This study shows the importance of both obtaining a definite history of patients and sequential radiologic imaging to make a differential diagnosis between the foreign bodies and cystic or noncystic tumors and inflammatory lesions of the mandible.

Features and management of intracranial mandibular condyle dislocation after trauma.

BACKGROUND: Dislocation of the mandibular condyle into the middle cranial fossa is rare in clinics. It often occurs when the mouth is open wide during the injury. It causes restriction of mandibular motion, lower facial asymmetry, pain in the temporomandibular joint (TMJ), etc. OBJECTIVE: To introduce the features of intracranial mandibular condyle dislocation and discuss the management to this kind of trauma. MAJOR FINDINGS: In this paper, the authors present two cases, describing the diagnosis, surgical management, and 1-year follow-up evaluation. The results of the authors' treatment to intracranial mandibular condyle dislocation were satisfactory and stable, and no surgical complications were detected. CONCLUSION: Advanced imaging studies are mandatory for exact diagnosis and successful treatment of intracranial mandibular condyle dislocation, and individualized management is recommended.

Three-stage mandible reconstruction after firearm injury.

Firearm injuries in the lower jaw may cause significant loss of hard and soft facial tissues, resulting in aesthetic and functional deformity. In this article, we present a case of a patient who suffered avulsion of the soft and hard tissues of the left mandible body and symphysis. After the emergency treatment, the patient was referred to our service, and the treatment was performed in 3 stages: surgical reconstruction with vascularized fibula flap, distraction osteogenesis, and dental implant rehabilitation. During 5 years of follow-up period, the aesthetic and functional condition of the patient improved considerably.

Mandibular gunshot wound with bullet aspiration.

Urban violence continues to be an important source of penetrating craniofacial injuries in major trauma centers. Gunshot wounds to the mandible are a commonly treated condition by craniofacial surgeons. Some gunshot wounds are through-and-through injuries, but in many patients, the bullet enters with no visible exit wound. In such situations, the bullet's trajectory and final destination are certainly important to the craniofacial surgeon in the extent of bony damage but may also be of unforeseen consequence to the patient's airway and respiratory condition. We present a case of a patient who had a gunshot wound to the face with comminuted mandibular ramus fracture in which the bullet was unexpectedly found to be aspirated down the right mainstem bronchus. This is the first reported case of a completely intact bullet being aspirated after gunshot wound to the face in an adult patient. We present this case to illustrate a rare possible complication after penetrating mandibular injury and offer a strategy for management of such an occurrence.

Image-based evaluation of facial fractures in a child using computed tomography.

This article describes the case of a boy who had a fracture of the mandibular parasymphysis region associated with a fracture of the contralateral condyle. Panoramic and computed tomography images were used to monitor bone remodeling.

Bioplasty for vertebral fractures: preliminary results of a pre-clinical study on goats using autologous modified skin fibroblasts.

The debate is still ongoing about the long term effects of the mininvasive vertebral augmentation techniques and their usefulness in treating more complex cases where a bone inducing effect more than a merely bone substitution would be suitable, such as the vertebral fractures in young patients. We previously developed a clinically relevant gene therapy approach using modified dermal fibroblasts for inducing bone healing and bone formation in different animal models. The aim of this study is to show the feasibility of a minimally invasive percutaneous intrasomatic ex vivo gene therapy approach to treat thoracolumbar vertebral fractures and anterior column bone defects in a goat model.

Needle breakage during local anesthesia in the oral cavity--a retrospective of the last 50 years with guidelines for treatment and prevention.

Needle breakage in the oral cavity after local anesthesia is a common complication with possible serious complications of injuring vital structures. There are different possible reasons for needle breakage, with a main focus on preventable mistakes in treatment. In this study, an analysis of literature of the last 50 years as well as own cases has been performed to renew knowledge and prevention and therapy strategies for this serious complication. A systematic, multilingual review of medical literature from 1900 until today was conducted and information was evaluated systematically. In the majority of cases needle fracture happened during inferior alveolar nerve block. It is mainly a problem due to inadequate technique or the use of too thin needles for the performance of inferior alveolar nerve block. Different arguments about possible therapy strategies and methods exist. Basically, if a hypodermic needle fractures, it should be removed surgically under general anesthesia. To localize the fragment, use of either multi-plane X-rays or fluoroscopy with at least two reference needles in place or, if possible, of three-dimensional CT scans is recommended. This article shows, that despite progression in material, needle fracture is still an existing, preventable problem, if some basic rules are followed.

Distraction osteogenesis versus fibula free flap for mandibular reconstruction after gunshot injury: socioeconomic and technical comparisons.

BACKGROUND: Since the birth of maxillofacial surgery, ballistic injuries are a real challenge for surgeons. For more than 20 years, fibula free flap (FFF) became the criterion standard for mandibular reconstructions. But FFF is not always the perfect answer for mandibular reconstruction, and a technique named distraction osteogenesis (DO) was raised. The purposes of this study are to estimate the financial cost and reattempt for the patient each techniques in our experience to determine the best-choice criteria for mandibular reconstruction after gunshot injury. METHODS: We performed a retrospective study over the last 15 years, including 15 patients with a mandibular ballistic injury. Ten patients were treated with FFF, and 5 with DO. We evaluated the complications and morbidity encountered with each technique. We also decided to estimate the cost of different rehabilitations, including the cost of the device and hospitalization. RESULTS: In our study, the global cost of the DO protocol appears as not more expensive than the FFF one. Postoperative complications encountered during the FFF protocols were related to donor-site morbidity. The DO patient had pseudoarthrosis, mucosa irritation, or local infection. DISCUSSION: Our study demonstrated both the economic and technical interest of DO compared with the FFF for mandibular reconstruction. Thus, nowadays, DO appears as an alternative to the FFF for mandibular reconstruction, the main decisional criterion being the evaluation of the tissues dilapidated during the initial traumatism, but social environment of the patient shall also be considered.

Transoral extraction of an intramuscularly retained bullet.

Severity of injury resulting from facial firearm wounds varies according to many factors. The correct management of these lesions can be complex, and each can present peculiarities.In this paper, we report a case of a patient affected by a limited mouth opening caused by a penetrating injury of the mandible angle by a large-caliber bullet retained in the contralateral medial pterygoid muscle. The limited mouth opening did not allow the performance of traditional intubation, and the bullet's location in the muscle tissue imposed a careful surgical approach without determining any displacement of it and consequently more damages.

Design and Fabrication of Implants for Mandibular and Craniofacial Defects Using Different Medical-Additive Manufacturing Technologies: A Review.

Mandibular and craniofacial bone defects can be caused by trauma, inflammatory disease, and benign or malignant tumors. Patients with bone defects suffer from problems with aesthetics, speech, and mastication, resulting in the need for implants. Conventional methods do not always provide satisfactory results. Most of the techniques proposed by researchers in the field of biomedical engineering use reverse engineering, computer-aided design (CAD), and additive manufacturing (AM), whose implementation can improve the outcomes of reconstructive surgeries. Several literature reviews on this particular topic have been conducted. However, they provide mostly overviews of AM technologies for general biomedical devices. This paper summarizes the use of existing medical AM techniques for the design and fabrication of mandibular and craniofacial implants, and then discusses their advantages and disadvantages in terms of accuracy, costs, energy consumption, and production rate. The aim of this study is to present a comparative review of the most commonly used AM technologies to aid researchers in selecting the best possible AM technologies for medical use. Studies included in this review contain CAD designs of mandibular or cranial implants, as well as their fabrication using AM technologies. Special attention is paid to PolyJet technology, because of its high accuracy, and economical efficiency.

Study of cerebrospinal injuries by force transmission secondary to mandibular impacts using a finite element model.

Brain and cervical injuries are often described after major facial impacts but rarely after low-intensity mandibular impacts. Force transmission to the brain and spinal cord from a mandibular impact such as a punch was evaluated by the creation and validation of a complete finite element model of the head and neck. Anteroposterior uppercut impacts on the jaw were associated with considerable extension and strong stresses at the junction of the brainstem and spinal cord. Hook punch impacts transmitted forces directly to the brainstem and the spinal cord without extension of the spinal cord. Deaths after this type of blow with no observed histological lesions may be related to excessive stressing of the brainstem, through which pass the sensory-motor pathways and the vagus nerve and which is the regulatory center of the major vegetative functions. Biological parameters are different in each individual, and by using digital modeling they can be modulated at will (jaw shape, dentition…) for a realistic approach to forensic applications.

Role of multidetector row computed tomography in the management of mandible traumatic lesions.

Facial injuries are common and must be radiologically evaluated to detect fractures, to determine their morphology and topography, and to assess adjacent soft-tissue damage. Spiral multislice computed tomography is progressively replacing conventional films for mandible traumatic lesions because it reveals the multiplicity of fragments, the degree of dislocation and rotation, and the extent of skull base involvement. Computed tomography is also very useful in the evaluation of condylar fractures, to determine the best choice for surgical treatment, open or close. 3-dimensional (3D) computed tomography images can display condylar fractures, but also all mandibular fractures, accurately and directly, and are very useful for surgeons to select treating methods of condylar fractures. The demonstration by imaging of the involvement of key anatomic structures is essential to classify correctly the trauma and to select the best management.

Reconstruction of canine mandibular bone defects using a bone transport reconstruction plate.

OBJECTIVES: Reconstruction of mandibular segmental bone defects is a challenging task. This study tests a new device used for reconstructing mandibular defects based on the principle of bone transport distraction osteogenesis. METHODS: Thirteen beagle dogs were divided into control and experimental groups. In all animals, a 3-cm defect was created on one side of the mandible. In 8 control animals, the defect was stabilized with a reconstruction plate without further reconstruction and the animals were killed 2 to 3 months after surgery. The remaining 5 animals were reconstructed with a bone transport reconstruction plate, comprising a reconstruction plate with attached intraoral transport unit, and were killed after 1 month of consolidation. RESULTS: Clinical evaluation, cone-beam CT densitometry, three-dimensional histomorphometry, and docking site histology revealed significant new bone formation within the defect in the distracted group. CONCLUSION: The physical dimensions and architectural parameters of the new bone were comparable to the contralateral normal bone. Bone union at the docking site remains a problem.

[Experimental study of the efficacy and clinical use of Perfoost in cases of defect substitution and correction of face supporting tissues].

Positive properties and perspectivity of demineralized osseous allogenic implants were pointed to. Experimental model of primary osseous plasty of mandible defects was described. The comparison of character and pace of reparative osteogenesis in experimental bone defects with Perfoost use and without transplantation was done. Perfoost had expressed osteoinductive and osteoconductive properties providing quicker reparative osteogenesis. In clinic osseous plasty operations of upper, middle and lower parts of face were done with the use of Perfoost. All in all 14 operations in 13 patients were conducted: in 3 patients - contour plasty of frontal region of head, in 5 patients- deformation correction of zygomatic region, lower edge and bottom of eye-socket; in 5 patients - defect substitution of mandible body and branch of the 8-10 cm length (in combination with titanium plates). In 2-3 months after operation the first signs of transplant rebuilding were detected during X-ray control. The expressed rebuilding of Perfoost with its substitution by newly formed bone was seen in 1-1.5 year. No complications followed, terms of observation - up to 8 years.

Dipyridamole Augments Three-Dimensionally Printed Bioactive Ceramic Scaffolds to Regenerate Craniofacial Bone.

BACKGROUND: Autologous bone grafts remain a standard of care for the reconstruction of large bony defects, but limitations persist. The authors explored the bone regenerative capacity of customized, three-dimensionally printed bioactive ceramic scaffolds with dipyridamole, an adenosine A2A receptor indirect agonist known to enhance bone formation. METHODS: Critical-size bony defects (10-mm height, 10-mm length, full-thickness) were created at the mandibular rami of rabbits (n = 15). Defects were replaced by a custom-to-defect, three-dimensionally printed bioactive ceramic scaffold composed of ß-tricalcium phosphate. Scaffolds were uncoated (control), collagen-coated, or immersed in 100 µM dipyridamole. At 8 weeks, animals were euthanized and the rami retrieved. Bone growth was assessed exclusively within scaffold pores, and evaluated by micro-computed tomography/advanced reconstruction software. Micro-computed tomographic quantification was calculated. Nondecalcified histology was performed. A general linear mixed model was performed to compare group means and 95 percent confidence intervals. RESULTS: Qualitative analysis did not show an inflammatory response. The control and collagen groups (12.3 ± 8.3 percent and 6.9 ± 8.3 percent bone occupancy of free space, respectively) had less bone growth, whereas the most bone growth was in the dipyridamole group (26.9 ± 10.7 percent); the difference was statistically significant (dipyridamole versus control, p < 0.03; dipyridamole versus collagen, p < 0.01 ). There was significantly more residual scaffold material for the collagen group relative to the dipyridamole group (p < 0.015), whereas the control group presented intermediate values (nonsignificant relative to both collagen and dipyridamole). Highly cellular and vascularized intramembranous-like bone healing was observed in all groups. CONCLUSION: Dipyridamole significantly increased the three-dimensionally printed bioactive ceramic scaffold's ability to regenerate bone in a thin bone defect environment.