Discussion
Maxillofacial traumas have been associated with 14 to 17% of all facial injuries (Gassner et al., 2003), however, the incidence of severe or complex maxillofacial trauma seems to have decreased over the past 10 years (Mast et al., 2015). The most common etiology of mid-facial traumas are motor vehicle accidents followed by interpersonal assaults (Haug et al., 1990). These traumas more commonly occur in males rather than females and most frequently in the second and third decades of the life as a result of motor vehicle accidents, assaults, falls, and domestic or occupational accidents (VandeGriend et al., 2015). Global trends tend to show an increasing male/female ratio, specifically in societies were women are mostly confined to home (Boffano et al., 2014).
The devastating nature of maxillofacial defects make reconstruction of the maxilla and mandible challenging, due to multiple required surgeries and extensive rehabilitation phase. These patients often suffer signs and symptoms consistent with anxiety, depression, or post-traumatic stress disorder (Kelly and Drago, 2009). Restoration of the structural integrity as well as rehabilitation in order to retain functional and esthetic demands of the patient should be the primary goal of treatment (Cakan et al., 2006, Balla et al., 2016).
All patients presenting with severe facial traumas should be managed according to Advanced Trauma Life Support (ATLS) guidelines. Intracranial, cervical spine, thoracic, abdominal and other sever extremity injuries must be ruled out or managed before tackling the facial reconstruction (Bellamy et al., 2013, Vaca et al., 2013, Sharma and Dhanasekaran, 2015).
High-definition computerized tomography (CT) scans with thin slices and three-dimensional reconstruction are invaluable in examination, treatment planning, and long-term management of facial traumas and have become a necessity in today’s management modalities of facial traumas (Hoelzle et al., 2001).
The face is composed of three vertical and three horizontal buttresses which play an effective role in distributing and absorbing the forces of induced trauma in order to prevent them from affecting the brain. Properly aligned skeletal buttresses gives structural and functional stability and integrity to the middle third of the face. Therefore, proper reconstruction of these key components of the midface is imperative (Sharma and Dhanasekaran, 2015).
In this case, we used submental intubation, as it is safe and easy to achieve without the need of any specialized equipment. Furthermore, it causes no interference in achieving occlusion intraoperatively and reducing the compartments of the midface. Surgical access was obtained through expansion of existing lacerations for visualization of underlying skeletal structures. In order to maintain nasal airway patency, two nelaton catheters were inserted in nostrils. Comminuted left orbital floor was totally reconstructed with titanium mesh. Also, bilateral frontal walls of the maxillary sinus were reconstructed by titanium mesh plates. The remaining fractured structures were reduced and fixed using microplate and screws in an outside-to-inside fashion and a primary stabilization of mid-facial structures was obtained.
One of the main consequences of maxillofacial traumas, is destruction of the teeth and teeth bearing alveolar bone. Oral rehabilitation utilizing dental implants of these patients must be carried out according to the following concepts: 1. the biological and anatomical features relative to the bone tissue to be treated with surgery; 2. utilization of a minimally invasive surgical techniques; 3. optimal management of peri-implant soft tissues; 4. evaluation of the shape and surface geometry and the type of dental implant required; 5. ensuring proper placement and alignment of the implant in the bone crest (Figliuzzi et al., 2017). A key determining factor for a proper osseointegration of implants is to have a quantity of bone that measures at least 2mm around the implant (Brånemark et al., 1969, Brånemark et al., 1977). In this case, we scheduled a three-stage oral rehabilitation plan including maxillary ridge augmentation with autogenous iliac bone graft and maxillary and mandibular implant-supported fixed prosthesis.