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Panfacial injuries are those that involve trauma to the lower, middle, and upper facial bones. They often are accompanied by multisystem- or polytrauma and require a team approach for management. Although stabilization of the overall status of the patient takes precedence, early and total restoration of facial form and function should be the goal of the maxillofacial surgeon.
Most of the scientific papers concerning facial osteotomies are focused on the surgical procedures. However, the most important thing to consider is how to go to the right indication and not how to do it. By an only morphological approach, as we can do with dental casts and cephalometric studies, it is obvious that we forget the functional factors. They nevertheless are essential to consider. Their knowledge permits understanding the physiopathology of the deformity and avoiding the postsurgical relapses. The main five factors concern: the dentoalveolar corridor, between tongue and orbicularis oris muscle, the facial bone growth modeling by functional matrix, the relations between upper incisors, lower incisors and lips, the posterior airway and the rest position of the tongue, the vertical muscular balance. Surgery has to normalize the abnormal function which is at the origin of the abnormal morphology. For this reason, maxillary surgery is better than mandibular surgery for the correction of a Class III deformity. Moreover, the transversal and vertical dimensions are always to be considered at the light of the functional parameters. Most of cases of dentofacial deformities are to be treated by bimaxillary osteotomies, including often transversal and/or vertical modifications. When the anatomical sites of these surgical procedures are determined, then we have to make an aesthetic facial profile simulation to validate the total amount of the bone displacements (cf. Part 2).
This study further defines the craniofacial malformations induced by triamcinolone acetonide in the rhesus monkey. Ten timed-mated pregnant rhesus monkeys (Macaca mulatta) received intramuscular injections of 10 mg/kg TAC on days 23, 25, 27, 29, and 31 of gestation. Results of previous experiments with rhesus and bonnet monkeys and baboons indicated that specific craniofacial and brain malformations could be induced with TAC during this period of pregnancy (Hendrickx et al., '80). Stage-matched TAC-treated and control embryos (stages 17-18 and 22) and age-matched TAC-treated and control fetuses (50, 60, and 70 days gestation) were removed by hysterotomy. Stage 17-18 TAC embryos appeared grossly normal but histologic evaluation revealed a shortened anlage of the posterior cranial base. Stage 22 TAC embryos and all TAC fetuses exhibited craniofacial dysmorphia and encephalocele. The developing sphenoid was the earliest affected and most severely malformed bone. Its defects included reduced anterioposterior and transverse dimensions, reduced orbitosphenoid and alisphenoid, abnormal pituitary fossa, and reduced dorsum and tuberculum sellae. In addition, shortening of the posterior cranial base and decreased cranial base angle was a consistent finding in the treated embryos and fetuses. Decreased ossification and remodeling in the facial bones and abnormal position due to the malformed sphenoid occurred.
Titanium implants were placed surgically into the maxillary, zygomatic, frontal, and occipital bones of four pigtail monkeys. After a 4-month healing period, the implants were exposed and abutments were placed. Extraoral traction appliances were then attached to the abutments. The cranial implants were used to support the framework of the traction appliance; those in the facial bones were used to attach springs that delivered a protraction force. The application of force varied among animals. In animal A, the force was applied to the maxilla. In animal B, the force was applied to the zygomatic bones. Animals C and D had force applied to both the maxillary and zygomatic bones. A tensile force of 600 gm per side was maintained until approximately 8 mm of maxillary anterior displacement had occurred. This amount of movement required 12 weeks of force application in animals A and B, and 18 weeks in animals C and D. Cephalometric and dry skull analyses showed that the amount of skeletal protraction was significant. The findings also demonstrated that it was possible to control the direction of maxillary protraction. The facial implants remained immobile throughout the experiment.
Olfactory neuroblastoma is a malignant, slow growing, neurogenic tumor that originates in the olfactory mucosa of the upper nasal cavity. We report a case of olfactory neuroblastoma that presented with exuberant hyperostosis of the facial bone during the course. This unusual radiological finding has been discussed with literature review.
From 1971 to 1982, 1316 patients suffering from fractures of this kind underwent treatment. In 200 patients out of them concomitant lesions could be demonstrated. The therapy of fractures of the facial bone should be practised in close cooperation with the oral surgeon and without loss of time.
INTRODUCTION: Facial nerve palsy results in the loss of facial expression and is most commonly caused by a benign self-limiting inflammatory condition, known as Bell's palsy. However, there are other conditions which may result in injury of the seventh cranial nerve and the radiologist should be familiar with their imaging appearances. MATERIALS AND METHODS: The relevant anatomy of the facial nerve and pathology which may affect the intratemporal portion of the nerve is described. The role of imaging and choice of imaging modality is also reviewed. RESULTS: High-resolution computer tomography(HRCT) images of the temporal bone and magnetic resonance(MR) images of the facial nerve from 11 patients who presented with facial nerve palsy were used to illustrate how intratemporal facial nerve injury of other aetiologies can mimic Bell's palsy. The typical imaging appearance of Bell's palsy was also presented. CONCLUSIONS: Most patients with suspected Bell's palsy do not require radiologic imaging. However, when symptoms progress, persist or when there is multiple cranial nerve involvement, recurrent symptoms or subacute onset of facial nerve palsy, causes other than Bell's palsy should be considered.
Hypoplasia and retrusion of the midfacial skeleton may only involve the dentoalveolar area or central facial region (nasal and paranasal [Binder's syndrome]) or the whole midface (paranasal, maxillary, malar, and zygomatic areas). The principal clinical findings are flattened paranasal, cheek, and malar areas. Class III malocclusion or normal dental occlusion can also be present. Treatment of midface retrusion is difficult because the final result depends on a high degree of harmonic aesthetic appreciation, the use of adequate surgical technique (adequate facial osteotomy), and the final relation obtained between soft tissue and facial bones. Many surgical treatments have been proposed for correction of midfacial retrusion. A new osteotomy is proposed involving advancement of maxillary and malar bones and the lower half of both zygomatic arches, when the whole midfacial skeleton is retrused and hypoplastic (both maxillary and malar bones are involved). The orbital osseous structures are not included in the osteotomy; the infraorbitary nerve remains intact. Using this technique, all clinical features are corrected. The advancement and mobilization of the whole body of the maxillary and malar bones along the lower part of the zygomatic arch contribute to three-dimensional facial reconstruction because they produce an increase in anteroposterior projection of the middle third facial region. Rigid internal fixation by means of miniplates and screw of 1.5 or 2 mm on four principal maxillary buttresses is used. No onlay bone grafts are used for obturing the gaps of osteotomy.
Leontiasis ossea (leonine facies) or cervical canal stenosis are rare complications of polyostotic fibrous dysplasia (PFD). This case report documents dramatic leontiasis ossea in PFD as well as post traumatic cervical cord contusion due to hyperextension injury in a patient with generalized PFD involving the cranio-facial bones, axial skeleton and entire spine with secondary cervical canal stenosis. Cervical cord contusion has not been reported earlier in PFD.
This topic summarizes basic principles of the development and the postnatal growth of the craniofacial skeleton. The different stages involved in the progressive ossification of facial bones are exposed: the intramembranous ossification, the endochondral (intracartilagenous) ossification and the changes (remodelling and relocation) associated with periosteal and endosteal membranes.
PURPOSE: The purpose of this study was to identify the contribution of ingested lead particles to elevated blood lead concentrations in victims of gunshot injury to the maxillofacial region. PATIENTS AND METHODS: As part of a larger study of the effects of retained lead bullets on blood lead, a retrospective review of study findings was completed on 5 of 8 patients who sustained injuries to the maxillofacial region. These 5 patients were recruited into the larger study within 11 days of injury and showed a penetration path for the projectile that engaged the upper aerodigestive tract. All subjects were recruited from patients presenting for care of their gunshot injuries to a large inner-city trauma center with a retained bullet resulting from a gunshot injury. An initial blood lead level was measured for all recruited patients and repeated 1 to 17 weeks later. Medical history was taken along with a screening and risk factor questionnaire to determine other potential or actual sources (occupational/recreational) of lead exposure. (109)Cd K-shell x-ray fluorescence determinations of bone lead were completed to determine past lead exposure not revealed by medical history and risk factor questionnaire. Radiographs taken of the abdomen and chest, required as a part of the patient's hospital care, were retrospectively reviewed for signs of metallic fragments along the aerodigestive tract. RESULTS: All 5 patients retained multiple lead pellets or fragments at the site of injury, sustained fractures of the facial bones, and showed increases in blood lead. Three of the 5 study subjects who sustained maxillofacial gunshot injuries involving the mouth, nose, or throat region showed metallic densities along the gastrointestinal tract indicative of ingested bullet fragments. Each patient with ingested bullet fragments showed rapid elevation of blood lead exceeding 25 microg/dL and sustained increases well beyond the time when all ingested fragments were eliminated. A 3-year follow-up on these 3 patients showed significantly sustained elevation of blood lead but less than that observed during the initial 6 months after injury. None of the 5 study subjects showed any evidence of metallic foreign bodies within the tracheobronchial regions indicative of aspiration. CONCLUSION: Ingestion of lead fragments can result from gunshot injuries to the maxillofacial region and may substantially contribute to a rapid increase in blood lead level. Prompt diagnosis and elimination of ingested lead fragments are essential steps necessary to prevent lead being absorbed from the gastrointestinal tract. Increased blood lead in victims after gunshot injuries must be fully evaluated for all potential sources, including recent environmental exposure, absorption of lead from any remaining bullets in body tissues, and the possibility of mobilization of lead from long-term body stores such as bone.
BACKGROUND: In the beginning of the development of facial osteosynthetic techniques only relatively thick plates were available. Since then various mini- and micro-plating systems were developed for the midfacial and forehead regions. As so many different systems with different sizes are available, it is important to know which systems are appropriate for which indications. Therefore, the aim of this study was to add knowledge to some aspects of the differential indications of different systems for the middle and upper facial regions. METHODS AND PATIENTS: 1. The pull-out forces of seven different mini- and microscrews were measured. 2. The thicknesses of the facial bone were measured at 11 different points in 10 skulls. 3. The clinical experiences of midfacial and upper facial osteosynthesis in 45 patients were summarised. RESULTS: The pull-out forces increase with increasing bone- and screw-thickness and also substantially depend on the design of the screws. Although the bone thicknesses in the mid and upper facial region vary considerably, all investigated regions are suitable for osteosynthesis. In none of our patients any complication occurred that was related to the osteosynthesis. CONCLUSIONS: Microsystems with screw diameters of 0.8 mm (Howmedica) are suited for fractures of the nasoethmoidal complex. Providing the same thickness as the microplates the Panfixsystem (Howmedica) offers a better holding strength especially when using the 1.3 mm screws, and is easier to handle. For stabilising fractures of the zygoma, which might dislocate postoperatively due to the pulling force of the masseteric muscle, we still feel that the miniplating technique with compression is the method of choice.
Thirteen children who had major extirpative surgery of the maxilla or the mandible were followed up an average of five years postoperatively. They ranged in age from three months to eleven years. Facial and oral photographs, cephalograms and cephalometric analysis, and plaster dental models were used to document longitudinal and cross-sectional growth patterns; Our experiences in this limited number of cases has indicated the following: (1) Extensive extirpation of facial bones may be performed in children without significantly jeopardizing function or growth. (2) The roots of healthy teeth may be resected without fear of their noneruption or early loss; loss of sensation with continued viability is the rule. (3) The use of an iliac bone crib with particulate grafts has proved a highly successful means of reconstruction of the mandible in children. (4) Particulate bone has proved to be an effective means of reconstructing large contour defects of the mandible caused by enucleating large tumors in children.
This clinical report describes an apparent change in the position of a metal ceramic crown cemented, for approximately 1 decade, on a single anterior implant. The continuing growth of the adult facial bones is presented as a plausible explanation for this clinical scenario.
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Analysis of x-ray parameters of the facial skull in 102 children and adolescents directed for orthodontic treatment because of occlusion abnormalities showed that the changes in the dentition ratio are caused by disorders in the growth and formation of facial bones and skull base. X-ray characteristics of different types of such disorders are presented.
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OBJECTIVE: After a wide survey of the literature, the results of a clinical-statistic study carried out on twelve cases of maxillo-facial bones fibrous dysplasia, diagnosed and treated at the Oral and Maxillo-Facial Surgery Department of the II University of Naples, are reported. EXPERIMENTAL ASSAY: Retrospective study. MATERIALS AND METHODS: All the patients examined showed fibro-osseus lesions involving the mandible in eight cases, the maxilla in three cases and the frontal bone in one case. Seven patients were females and five males, aged between nine and seventy-two years. The surgical treatment was carried out on eleven patients: four cases were treated by complete surgical excision of the fibro-osseous lesions and seven cases by a conservative removal of the portion of the lesion contributing to the bone deformity. RESULTS AND CONCLUSIONS: All cases examined involved maxillo-facial skeleton structures as a sole localization, confirming that the polyostotic forms are more infrequent than the maxillary monostotic ones. The distribution of the cases according to age classes and lesion localization showed a higher incidence of fibrous dysplasia in the third decade of life and a clear predilection for the mandible. The observation of active lesions in old age shows that the disease may evolve also after the growth. The cases treated by radical excision of the lesions have not been followed from relapse; on the contrary three of the seven cases treated by conservative excision relapsed after a few years.