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.