Reconstructive surgery for complex midface trauma using titanium miniplates: Le Fort I fracture of the maxilla, zygomatico-maxillary complex fracture and nasomaxillary complex fracture, resulting from a motor vehicle accident.

Abstract

Maxillofacial injuries resulting from trauma can be a challenge to the Maxillo-Facial Surgeon. Frequent causes of these injuries are attributed to automobile accidents, physical altercations, gunshot wounds, home accidents, athletic injuries, work injuries and other injuries. Motor vehicle accidents tend to be the primary cause of most midface fractures and lacerations due to the face hitting the dashboard, windshield and steering wheel or the back of the front seat for passengers in the rear. Seatbelts have been shown to drastically reduce the incidence and severity of these injuries. In the United States seatbelt laws have been enacted in several states thus markedly impacting on the reduction of such trauma. In the Philippines rare is the individual who wears seat belts. Metro city traffic, however, has played a major role in reducing daytime MVA related trauma, as usually there is insufficient speed in traffic areas to cause severe impact damage, the same however cannot be said for night driving, or for driving outside of the city proper where it is not uncommon for drivers to zip into the lane of on-coming traffic in order to overtake the car in front ... often at high speeds. Thus, the potential for severe maxillofacial injuries and other trauma related injuries increases in these circumstances. It is however unfortunate that outside of Metro Manila or other major cities there is no ready access to trauma or tertiary care centers, thus these injuries can be catastrophic if not addressed adequately. With the exception of Le Fort II and III craniofacial fractures, most maxillofacial injuries are not life threatening by themselves, and therefore treatment can be delayed until more serious cerebral or visceral, potentially life threatening injuries are addressed first. Our patient was involved in an MVA in Zambales, seen and stabilized in a provincial primary care center initially, then referred to a provincial secondary care center for further stabilization before his transfer to Manila and then ultimately to our Maxillo-Facial Unit. There was a two week-plus delay in the definitive management because of this. As a result of the delay, fibrous tissue and bone callus formation occurred between the various fracture lines, thus once definitive fracture management was attempted, it took on a more reconstructive nature. Hospital based Oral and Maxillo-Facial Surgeons are uniquely trained to manage all aspects of the maxillo-facial trauma, and their dental background uniquely qualifies them in functional restoration of lower and midface fractures where occlusion plays a most important role. Likewise, their training in clinical medicine which is usually integrated into their residency education (12 months or more) puts them in a unique position to comfortably manage the basic medical needs of these patients. In instances where trauma may affect other regions of the body, an inter-multi-disciplinary approach may be taken or consults called for. In this instance, an opthalmology consult was important. In fresh trauma, often seen in major trauma centers (i.e. overseas), a "Trauma Team" is on standby 24 hours a day, and is prepared to assess and manage trauma patients almost immediately upon their arrival in the ER. The trauma team is usually composed of a Trauma Surgeon who is a general surgeon with subspecialty training in traumatology who assesses and manages the visceral injuries, an Orthopedic Surgeon who manages fractures of the extremities, a Neurosurgeon for cerebral injuries and an Oral and Maxillo-Facial Surgeon for facial injuries. In some institutions, facial trauma call is alternated between the "three major head and neck specialty services", namely Oral and Maxillo-facial Surgery, Otolaryngology-Head & Neck Surgery and Plastic & Reconstructive Surgery. (ABSTRACT TRUNCATED)