Case Presentation
A 53-year-old man was presented to the emergency department of Shahid
Beheshti hospital in Babol, Iran, following a motor vehicle accident
involving the patient getting hit by a high-velocity lorry as he was
crossing the street. Upon presenting to the emergency department,
neurological and surgical evaluations were done and intracranial,
cervical spine, thoracic, abdominal and other sever extremity injuries
were ruled out. He had sustained soft tissue lacerations extending from
supraorbital regions to upper lip with almost complete destruction of
nasal structures and hemorrhage (Figure 1). Furthermore, intraoral
examinations revealed intact maxillary edentulous and mandibular
partially edentulous ridge. A computerized tomography (CT) scan with
three-dimensional reconstruction was prompted and it further depicted
the extent of the injury. No concomitant injuries in upper and lower
extremities were observed. Preoperative laboratory tests revealed normal
findings.
Regarding CT scan analysis, left orbital floor was completely
comminuted. Furthermore, bilateral pterygoid plates fractures and
bilateral comminutions of zygomatic buttresses and frontal walls of
maxillary sinuses extending to inferior orbital rim and nasofrontal
suture were observed. Fractures in left zygomatico-sphenoid and
zygomatico-frontal suture and left zygomatic arch were depicted. Also,
CT scan imaged a Naso-Orbito-Ethmoidal (NOE) fracture. Moreover, a
unilateral coronoid process fracture just above the mandibular notch was
noted on the right side. Final diagnosis for the patient consisted of
Lefort II, left zygomatico-maxillary complex (ZMC), NOE type 3b, left
orbital blow-out, and right mandibular coronoid fractures [21]
(Figure 2).
Patient went under general anesthesia through submental endotracheal
intubation. Surgical access was obtained through expansion of existing
lacerations for visualization of underlying skeletal structures.
Following a thorough and rigorous irrigation with saline, airway patency
was maintained using two nelaton catheters in nostrils (Figure 3). After
a laborious 9-hour surgery, comminuted structures including left orbital
floor and bilateral frontal walls of the maxillary sinus were
reconstructed by titanium mesh plates and 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. Both eyes were salvaged. Suturing of the
lacerations were accomplished except the nose with the nelaton catheters
inside the nostrils. Nelaton catheters were removed and suturing of the
nose were completed in final stage. Post-operative clinical image and
3D-reconstructed CT scan are shown in figure 4 and 5.
He was admitted for seven days in the hospital and then subsequently
discharged. During post-operative period, no complications including
infection, wound dehiscence or retrobulbar hemorrhage were reported.
Ocular examination after surgery revealed anisocoric. Normal findings in
the right eye and decreased vision accuracy in the left eye was reported
(Figure 6).
Following a year after the initial surgery, the patient referred to us
seeking rehabilitation of the edentulous areas in his mouth. He used a
maxillary complete denture and mandibular partial denture that were
broken in the accident. Cone Beam Computed tomography (CBCT) and
orthopantomogram (OPG) were then obtained which revealed inadequate bone
width in the maxilla and therefore necessitating a crestal bone
augmentation and bone grafts (Figure 7). Initial treatment plan
consisted of fixed implant prosthesis on maxilla and removable
overdentures in the mandible. Oral rehabilitation was scheduled for this
patient in three stages. In the first stage and under general
anesthesia, the reconstruction of maxillary atrophic ridge was done
using autogenous bone graft harvested from anterior iliac spine. The
remaining four mandibular teeth were then extracted and 4 implants
(Osstem® fixture, TS III SA) inserted immediately
during this stage. During the healing period, no infection, wound
dehiscence or tenderness were observed on the graft recipient or donor
sites. After 6 months, patient recalled for implant insertion with a new
CBCT of augmented sites (Figure 8). Therefore, 8 maxillary implants
(Neodent® Acqua Drive) were inserted in augmented
sites. After a few early follow-up sessions, the patient decided to have
a fixed prosthesis for the mandible as well, therefore, 3 additional
implants (Osstem® fixture, TS III SA) were placed in
the mandible (Figure 9). After 4 months, maxillary and mandibular fixed
prosthesis was delivered to the patient (Figure 10 and 11).