Management of Mid-Facial Fracture Complicated by Pseudoaneurysm of Posterior Superior Alveolar Artery.

Facial fractures, particularly mid-facial fractures, can result in various complications, such as functional and esthetic problems. Prompt reconstruction of the fractured bones is crucial for restoring normal anatomy and function and preventing complications. However, such procedures can be complex and carry the risk of potential complications. The authors report the case of a 27-year-old man who underwent open reduction and internal fixation of the left zygomatic complex fracture and reconstruction of the left inferior orbital wall. During the surgery, heavy bleeding from the posterior superior alveolar artery due to a broken bone near the pterygomaxillary region caused a prolonged surgery time and the development of a pseudoaneurysm. The pseudoaneurysm was eventually treated with superselective transcatheter embolization using 25% N-Butyl cyanoacrylate glue. This case highlights the challenges in the management of mid-facial fractures and the potential complications that can arise during surgery, particularly when dealing with the pterygomaxillary region.

Virtual Surgical Planning and 3-Dimensional Printing for the Treatment of Zygomaticomaxillary Complex and/or Orbital Fracture.

BACKGROUND: Traditionally, in zygomaticomaxillary complex and orbital fractures, miniplates and titanium orbital mesh are used and adapted intraoperatively, which may cause fatigue of the metal and increase the surgical time. Recently, computer-assisted surgery and 3-dimensional printing enable the surgeon to employ 3-dimensional segmentation and mirroring tools, which mimic the pretraumatized anatomy on which the miniplates and titanium orbital mesh are preoperatively molded to precisely duplicate the orbital volume, enophthalmos, and zygomatic bone position. AIM: To evaluate the results of computer technology using 3-dimensional printing model to prebend miniplates and titanium orbital mesh in the restoration of orbital volume, enophthalmos, and zygomatic bone position in the initial management of patients with zygomaticomaxillary complex and/or orbital fractures. PATIENTS AND METHODS: This prospective clinical study included 10 Iraqi male patients who met the eligibility criteria and subjected to open reduction and internal fixation utilizing virtual surgical planning and a 3-dimensional model to prebend miniplates and titanium orbital mesh as a treatment modality for facial fractures. The data were analyzed according to the orbital volume, enophthalmos, zygomatic bone position, age, gender, etiology of the fracture, and complications. The patients were radiographically followed up with a computed tomography scan at 4 months postoperatively. The statistical analysis was performed using percentages, the mean±SD, Shapiro-Wilk test, Paired t test, One Way Anova, and Independent t test. RESULTS: The age of the patients ranged from 18 to 66 years, with an average of 28.6 years and a SD of±14.5 years. Regarding gender, all patients were males. By utilizing virtual surgical planning and 3-dimentional model to prebend miniplates and titanium orbital mesh and concerning the fracture types, which include the zygomaticomaxillary complex, orbital, and combined fractures, there was no significant difference between the measurement of intact side and 4 months postoperatively in orbital volume, enophthalmos, and zygomatic bone position ( P >0.05). CONCLUSION: This study demonstrated that computer-aided techniques, virtual planning, and the use of prebend miniplates and titanium orbital mesh enable anatomically precise reduction and fixation of the orbital, zygomaticomaxillary complex, and combined fractures regarding orbital volume, enophthalmos, and zygomatic bone position.

A Novel Method for Quantitative Three-Dimensional Analysis of Zygomatico-Maxillary Complex Symmetry.

OBJECTIVE: To develop a reliable and accurate method to quantify the symmetry of the zygomaticomaxillary complex (ZMC). METHODS: Virtual three-dimensional models were created from 53 computed-tomography scans: 15 healthy cases without maxillofacial disorders and 38 patients with ZMC fractures requiring surgical treatment.Asymmetry of the ZMC was measured using a mirroring and surface-based matching technique that uses the anterior cranial fossa as reference to determine the symmetrical position of the ZMC. The measure for ZMC asymmetry was defined as mean surface distance (MSD) between the ZMC-surface and the symmetrical position.Reliability of the method was tested in the 15 healthy cases. Inter-and intra-observer correlation coefficients (Ce) and variabilities were assessed. Accuracy was assessed by comparing ZMC asymmetry between healthy and ZMC fracture cases, and by assessing correlation of ZMC fracture severity with ZMC asymmetry. RESULTS: The average MSD of the 15 healthy cases was 1.40 ± 0.54 mm and the average MSD of the 38 ZMC fracture cases was 2.69 ± 0.95 mm ( P < 0.01). Zygomaticomaxillary complex asymmetry correlated with fracture severity ( P = 0.01). Intra-rater CC was 0.97 with an intra-rater variability of 0.09 ± 0.11 mm. Inter-rater Ce was 0.95 with an inter-rater variability of 0.12 ± 0.13 mm. CONCLUSIONS: Our method is reliable and accurate for quantitative three-dimensional analysis of ZMC-symmetry. It takes into account asymmetry caused by the shape of the ZMC as well as asymmetry caused by the position of the ZMC. CLINICAL RELEVANCE: This method is useful for the evaluation of ZMC asymmetry associated with congenital and acquired disorders of craniofacial skeleton, for surgical planning and for evaluation of postoperative results.

Extensive Post-Traumatic Surgical Emphysema Exacerbated by Cocaine Insufflation.

Surgical emphysema (SE) is characterized by air in the soft tissues causing a crackling sensation on palpation. In oral and maxillofacial surgery, it might occur using conventional air-driven dental hand pieces, as a complication of trauma and with cocaine insufflation.The subcutaneous air may travel through tissue planes causing cervicofacial emphysema, pneumothorax, and pneumomediastinum. It may carry bacteria and potentially lead to cellulitis or necrotizing fasciitis.The SE is usually a self-limiting entity requiring analgesia, close observation of the airway, occasionally prophylactic antibiotics, and rarely steroids. Although, the consensus on antibiotic and corticosteroid therapy is unclear.Here presented an unusual and extensive presentation of surgical emphysema. A 29 years old male presented with emphysema following a left orbital-zygomatic complex fracture and following intranasal cocaine insufflation. It extended from the temple to the parotid region, down into the neck and into the mediastinum. No surgical intervention was required. The patient was discharged after 24 hours of observation with a week-long course of co-amoxiclav antibiotics and no corticosteroids administration.Typical instructions following facial bone fractures are to avoid nose blowing because of the risk of SE, however, avoidance of drug habits is rarely considered. This case report highlights the importance of tailored advice to this particular patient cohort.

Prevalence of obstructive sleep apnea in male patients with surgically treated maxillary and zygomatic fractures

Background: Midface fractures can cause airway obstruction and breathing disturbances. The purpose of the present study was to determine the prevalence of undiagnosed obstructive sleep apnea (OSA) among patients with surgically treated maxillary and zygomatic fractures. Methods: We retrospectively analyzed the medical records of 44 patients who had undergone surgical treatment of maxillary or zygomatic fractures between Jan. 1, 2003, and Dec. 31, 2013 at a single centre. All participants underwent polygraphy testing and were asked to complete the STOP (snoring, tiredness, observed apnea and high blood pressure) questionnaire, Nasal Obstruction Symptom Evaluation (NOSE) scale and Epworth Sleepiness Scale. Results: There were 27 participants (61%) with maxillary fracture and 17 (39%) with zygomatic fracture. Obstructive sleep apnea was diagnosed in 24 (54%) of the 44 participants, of whom 15 (62%) had maxillary fractures and 9 (38%) had zygomatic fractures. Participants with OSA had a mean Apnea­Hypopnea Index (AHI) of 15.5 (standard deviation [SD] 9.7) events/h, compared to 2.4 (SD 1.5) events/h for those without OSA (p < 0.001). Of the 30 participants with nose obstruction, 18 (60%) had an AHI of 5 or greater. Conclusion: The results suggest that the prevalence of OSA was higher in surgical patients with midface fractures, independent of the type of fracture, than in the general population. The NOSE scale results showed significant correlation with the presence of OSA.

Contexte: Les fractures affectant la portion médiane du visage peuvent provoquer une obstruction des voies respiratoires et gêner la respiration. La présente étude avait pour but de déterminer la prévalence de l'apnée obstructive du sommeil (AOS) non diagnostiquée chez des patients ayant été traités chirurgicalement pour des fractures du maxillaire et de l'os zygomatique. Méthodes: Nous avons analysé rétrospectivement les dossiers médicaux de 44 patients ayant subi un traitement chirurgical pour une fracture du maxillaire ou de l'os zygomatique entre le 1er janvier 2003 et le 31 décembre 2013 dans un seul établissement. Tous les participants ont subi un test polygraphique et ont été invités à répondre aux questionnaires STOP (snoring, tiredness, observed apnea et high blood pressure), NOSE (Nasal Obstruction Symptom Evaluation), de même qu'à l'échelle de somnolence d'Epworth. Résultats: Vingt-sept participants (61 %) avaient subi une fracture du maxillaire et 17 (39 %) de l'os zygomatique. L'AOS a été diagnostiquée chez 24 participants sur 44 (54 %), dont 15 (62 %) avaient subi une fracture du maxillaire et 9 (38 %) une fracture de l'os zygomatique. Les participants qui présentaient une AOS avaient un indice d'apnée-hypopnée (IAH) moyen de 15,5 (écart-type [É.-T.] 9,7) événements/h, contre 2,4 (É.-T. 1,5) événement/h pour les participants indemnes d'ASO (p < 0,001). Parmi les 30 participants qui avaient une obstruction nasale, 18 (60 %) avaient un IAH de 5 ou plus. Conclusion: Ces résultats donnent à penser que la prévalence de l'AOS était plus élevée chez les patients opérés pour une fracture affectant la portion médiane du visage (indépendamment du type de fracture) que dans la population générale. Les résultats au questionnaire NOSE ont montré une corrélation significative avec la présence d'AOS.

Management of ocular dystopia and lacrimal pathway obstruction in old multiple midfacial fractures: Case report.

Midfacial fracture is discontinuity of the bone affect maxilla, palate, zygomatico-maxillary complex, nasal bones, orbits, nasal-orbital-ethmoid complex, and frontal sinus. Delayed treatment can lead to malunion or nonunion bone. A 28 years old man presented with epiphora of the left eye and upgaze diplopia. There were enophthalmos, hypoglobus of the left eye, flat nasal bridge, and depressed left malar eminence. CT scan examination revealed multiple fractures of left nasal bone, left and right anterolateral wall of maxillary sinuses, left medial orbital wall and orbital floor, and left zygomatic bone. Lacrimal irrigation test showed obstruction of left nasolacrimal duct. He underwent osteotomy and fixation with plate and screw, orbital floor reconstruction with silicone block implant, external dacryocystorhinostomy with silicone tube insertion procedure. In delayed treated malunion of midfacial fracture, fixation with plate and screw after refracture using an osteotome and orbital floor reconstruction with silicone block can be a good option for restoring normal anatomy. External dacryocystorhinostomy with silicone tube insertion is an effective treatment for post traumatic nasolacrimal duct obstruction.

Which craniofacial fractures are associated with external auditory canal bleeding?

PURPOSE: External auditory canal bleeding (EACB) after facial trauma has been strongly associated with skull base fractures; however, EACB also can occur with other craniofacial fractures. The aim of this study was to analyze the frequency and causes of EACB in different craniofacial fracture types. PATIENTS AND METHODS: The investigators used a retrospective cohort study design and enrolled a sample composed of patients with craniofacial fractures evaluated and treated from April 2006 through December 2011. The predictor variable was fracture type, which was categorized into 4 types: skull base fracture, midface fracture, and mandibular fracture with and without involvement of the condyle. The frequency of EACB among fracture types was compared with SPSS 13.0 (SPSS, Inc, Chicago, IL) and χ(2) test. Computed tomographic (CT) scans were analyzed to determine the cause of EACB. RESULTS: EACB was found in 43 of 573 craniofacial fracture cases, with a frequency of 7.5%. There were 19 EACB sides in 123 skull base fracture cases (15.4%), 26 EACB sides in 150 mandibular fracture cases involving the 196 condyles (13.3%; of these 196 condyles, 92.3% were intracapsular condylar fractures [ICFs]), 2 EACB sides in 150 mandibular fracture cases not involving the condyle (1.3%), and 1 EACB case in 150 midface fracture cases (0.7%). Statistical analysis of EACB frequency for each fracture type showed a significant difference between skull base or mandibular fractures with condylar involvement and midface or mandibular fractures without condylar involvement (P < .05). However, there was no significant difference between skull base and mandibular fractures involving the condyle and midface fracture and mandibular fractures not involving the condyle (P > .05). CONCLUSIONS: EACB is uncommon in craniofacial fractures. The frequency varies significantly based on fracture type. Skull base fracture and mandibular ICF are the 2 main causes of EACB.

Prosthetic rehabilitation of a patient with unilateral dislocated condyle fracture after treatment with a mandibular repositioning splint: a clinical report.

This clinical report describes the use of a mandibular repositioning splint and the subsequent prosthodontic treatment of a unilateral dislocated condyle fracture for a patient whose injury resulted in significant mandibular deviation and malocclusion. The use of a mandibular repositioning splint considerably reduced the mandibular deviation, and a stable mandibular position was maintained with the definitive prosthesis.

Maxillofacial fractures in Pondicherry, India: An eight-year single centre retrospective study.

Background: The purpose of the present study was to analyze the etiology, incidence, pattern, and treatment modalities of patients with maxillofacial fractures treated at the Department of Dentistry of a medical college in Pondicherry during the period between June 2011 and June 2019. Materials and Methods: A retrospective epidemiological study of 277 patients treated for maxillofacial fractures between June 2011 and June 2019 was performed. Data regarding age, gender, etiology, site of the fracture, time of injury, presence of associated injuries, treatment modalities, and complications were recorded. Results: A total of 491 maxillofacial fractures were seen in 277 patients. These were 261 males (94.2%) and 16 females (5.8%) with a male to female ratio of 16.3:1. Most of the patients 79.8% were in the age group of 11 to 40 years. Most common cause of injury was Road Traffic Collisions (RTCs; 62.1%), followed by fall (20.2%), assault (14.4%) and others (3.3%). Fractures of the mandible (52.3%) and zygomatic complex (18.9%) were the most common maxillofacial fractures reported in our study. 196 patients sustained associated injuries with a prevalence of soft tissue injury (61.2%). Majority of fractures were treated with open reduction and internal fixation (ORIF; 71.9%) of patients followed by closed reduction (17.7%) and observation only (10.4%). Postoperative complications were presented in 16.8% of the patients in the study. Conclusion: RTC is the commonest cause of maxillofacial injury with a male predominance in our study. Mandibular and zygomatic complex fractures were the most common. ORIF remains the preferred method of treatment.s.

Orbital floor reconstruction with resorbable polydioxanone implants.

Many different materials are proposed for reconstruction of traumatic orbital floor defects. Donor-site morbidity of autologous transplants and infections or extrusions of nonresorbable implants lead to a widespread use of resorbable, alloplastic materials such as polydioxanone (PDS). The goal of this study was to evaluate the prevalence of orbital floor fracture-related problems after surgical treatment using PDS. Ophthalmologic and clinical examinations were performed at 194 patients before orbital floor reconstruction, 14 days and 6 months after surgery (approximate defect sizes: <1 cm², n=50; 1-2 cm², n=97; >2 cm², n=47). Clinical findings including the ocular motility, the sensibility of the infraorbital nerve, and the position of the globe were evaluated. For statistical analysis of categorical data, confidence intervals of percentages were determined. Linear relationships between 2 variables were assessed with Pearson correlation analysis. A reduced ocular motility was diagnosed in 60 patients (31%) before surgery; in 14 patients (7%), 2 weeks; and in 10 patients (5%), 6 months after surgery. Infraorbital hypesthesia was found in 120 patients (62%) before surgery; in 47 patients (24%), 2 weeks; and in 35 patients (18%), 6 months after surgery. An enophthalmos was present in 10 patients (5%) before surgery, and in 4 patients (2%), 6 months after surgery. Our data suggest that PDS is a suitable implant for orbital floor reconstruction with acceptable low rates of infraorbital hypesthesia, bulbus motility disturbances, and enophthalmos. Polydioxanone can also be used for orbital floor defects exceeding 2 cm².