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Throughout most of recorded human history, facial fractures have received either no treatment what so ever or only rudimentary surgical attention. The treatment of facial fractures has made more progress over the past two decades than in the entire two millenia before that. The authors describe how facial fractures have been treated since the New Kingdom in Ancient Egypt until today, with the methods of Stable Internal Fixation.
Radiographic imaging is an important tool in the assessment of facial trauma and the detection of underlying fractures or other injuries. To achieve the best possible cosmetic result, diagnosis and treatment of facial injuries must be accurate, thorough and prompt. This article reviews facial anatomy and discusses several types of mandible and facial fractures and their causes. It also reviews the diagnostic imaging techniques used to evaluate facial fractures, including a discussion of the most common views.
It is postulated that craniosynostosis is due to a growth abnormality in all or part of the cranial capsule. Release of the stenosed part in the first months of life will re-establish the balance between the rapidly growing brain and eye, and the cranial capsule. Three periods for operative treatment are described: early, intermediate and late. Only in the early period can operative treatment restore normal growth dynamics; in the late period the aim is correction of an established deformity. The relationship between cranial clefts and frontonasal encephaloceles is explored. If the space-occupying encephalocele is removed early, the distorted facial bones adopt a more normal position, whereas cranial clefts do not respond to early operation by remoulding. The treatment of the acquired deformities of acute cranio-facial trauma have taken on new perspectives with the application of the multi-disciplinary approach and surgical techniques developed in the treatment of congenital deformities resulting in considerable reduction in the period of hospitalisation.
UNLABELLED: McCune-Albright syndrome is a rare disorder caused by a somatic, constitutively activating mutation in the gene (GNAS1) encoding the subunit of the signal transducing guanine nucleotide binding protein (G protein). The condition is characterized by polyostotic fibrous dysplasia, cafe-au-lait pigmentation and multiple endocrine hyperfunction, most commonly gonadotropin-independent precocious puberty in girls. Our patient, a 16-year-old male, with radiologically confirmed polyostotic fibrous dysplasia in cranium, thoracic and pelvic girdles, spine and extremities was studied using planar 99mTc-hydroxymethyldiphosphonate bone scintigraphy and single photon emission computed tomography. Using bone scintigraphy, an unusually extensive and asymmetric fibrous dysplasia was observed in the cranium, face, ribs, femur, humerus, ulna, tibia and the vertebral column, all on the left side. The whole body scan revealed only a few foci on the right side. Single photon emission computed tomography demonstrated extensive unilateral involvement in the base of the skull, facial bones, maxilla and mandible. All the lesions reached only the midline. These findings formed the basis of further treatment, eg. reconstructive surgery of facial asymmetry. CONCLUSION: McCune-Albright syndrome should be considered in the differential diagnosis when interpreting extensive unilateral predominance in paediatric bone scans.
The second most frequently injured facial bone is the mandible. For this reason, the incidence of mandibular fractures remains high and will continue to represent a considerable percentage of acute major facial injuries encountered by reconstructive surgeons. Fortunately, to this date, complications have been relatively rare. We present our series evaluating the late sequelae from 135 patients treated by the Division of Plastic Surgery at the University of California, Davis Medical Center, Sacramento, California, for mandible fractures during the period July 1, 1987, to June 30, 1988. From this retrospective record review, we found only six patients who required correction of established traumatic deformities. We report the surgical procedure used in these six patients and an additional two patients referred to our center for surgery. From these eight patients, we delineate the anatomical and functional deformities of mandibular malunion as well as the etiological factors. We will present our surgical method using articulating dental models and occlusal splints, and the application of rigid internal fixation with miniplates and screws for stabilization. All patients in the study presented with either malocclusion or facial asymmetry. We were able to return to each of the patients satisfactory mandibular function and facial symmetry.
Fibro-osteo-cemental lesions of the jaw bones are a heterogeneous group of diseases which present problems in classification. Psammous desmo-osteoblastoma is one of four newly proposed entities (Makek 1983) and has until now been characterized by its light microscopic, clinical and radiological features. On electron microscopy this tumour exhibits fibroblastic (preosteoblastic), osteoblastic and osteocytic cells and a globular mineralization unlike the mineralization of the psammoma bodies. Immunohistological investigations with anti-osteonectin, a bone specific protein linking mineral to collagen, showed positive intracellular staining in all tumour cells and extracellular staining in the osteoid. The psammoma bodies were, however, not stained. These results confirm the view of the osteogenic histogenesis of psammous desmo-osteoblastoma, with an osteogenic differentiation of the tumour cells, bone formation and association of psammoma bodies which are not of bone origin. This combination of findings supports the view that psammous desmo-osteoblastoma represents a new and distinct entity occurring in desmal preformed cranio-facial bones which should be incorporated in a revised WHO-classification.
We developed a hydroxyapatite (HA) powder-carboxymethyl chitin composite (HA-CMC composite) that can be injected with a 14G needle by adding distilled water. We prepared Materials I (HA = 57.0 wt%) and II (HA = 40.2 wt%) and examined their biocompatibility and osteoconductivity. With a 2-mm skin stab, the material was injected on the calvarial bone of rats. The periosteum was denuded blindly in half of the cases and preserved in the other half of the cases. Simultaneously, the material was injected subdermally into the abdominal skin to examine diachronic volume alteration of the material. Our results indicated that the new materials had biocompatibility as high as that achieved with previously developed HA materials. The difference in HA concentration did not influence the osteoconductivity, but the periosteum and the soft tissue on the cranium seemed to be an obstacle to bone ingrowth. On the other hand, the volume alteration was significantly smaller in Material I than in Material II. This composite may be especially useful in facial bone augmentation because it can be injected with only a small skin stab. When used for that purpose, the periosteum of the host bone should be denuded to facilitate bone ingrowth, and Material I will be preferable to Material II in terms of the maintenance of the initial volume.
Eight cases of giant-cell reparative granuloma were encountered in the short tubular bones of the hands and feet. This entity was originally described by Jaffe as a jaw lesion. Subsequently the lesion was found in the skull and facial bones. The name "giant cell reaction" was applied to similar lesions found in the short tubular bones of hands and feet. Thirteen prior cases have been reported and none recurred. Of the eight new cases described herein, four have recurred one or more times, requiring further treatment. No association with hyperparathyroidism was found. We prefer to designate these lesions as giant cell reparative granulomas of extragnathic sites. Because of overlapping ultrastructural and light-microscopic features, as well as similar biologic behavior, we feel that aneurysmal bone cyst and these giant-cell reparative lesions represent related responses to intraosseous hemorrhage.
Twenty-seven temporal bone fractures in 25 pediatric patients were evaluated over a 6-year period. The diagnosis was confirmed with otoscopy and high-resolution computed tomography scans (HRCT). Three-dimensional reconstruction of high-resolution computed tomography scans were used to aid in the diagnosis. The most common fracture was an oblique fracture which is oriented in an axial or horizontal plane with the temporal bone. Facial nerve paralysis was found in 6 of our patients, which is less than the expected incidence when compared to adults. Hearing loss was found in 24 patients, the most common of which was conductive hearing loss, which had a higher incidence than expected when compared with adults.
Ossifying fibromas involving the tibia were seen in two patients. In both patients, the radiographic appearance of the lesions suggested fibrous dysplasia, but histopathologic evaluation demonstrated findings similar to ossifying fibroma of the mandible and facial bones. Radiologic and pathologic recognition of this entity is necessary for proper treatment.
Restriction of the mouth opening from a pathologic condition outside the temporomandibular joint is called a pseudo- or extra-articular ankylosis. The authors report two cases of severe post-traumatic pseudoankylosis. One case showed fibrous degeneration of the bilateral masseter muscles without a facial bone fracture, which caused severe trismus, a mouth opening of less than 2 mm, and gradually appeared after blunt injuries to the face. The other was a rare case accompanied with the bone formation in the masseter muscle and was diagnosed as myositis ossificans traumatica, which also presented as severe trismus, with a maximal mouth opening of 5 mm after facial violence. Both were surgically treated with dissection of the affected muscles. In addition, a hemicoronoidotomy was performed in the case of myositis ossificans traumatica. Although a conservative therapy with physical rehabilitation is the basic policy for the management of pseudoankylosis of the temporomandibular joint, a surgical treatment should be considered when the origin of the problems is an osteogenic character or severe extra-articular ankylosis resistant to conservative therapy before completion of true temporomandibular joint ankylosis.
Fractures of the maxillary facial bones, also described as LeFort fractures, are potentially disfiguring and potentially lethal injuries that require careful examination and expectant management skills. This review article provides an overview of facial anatomy, fracture patterns, patient assessment, and the specific management of patients with LeFort fractures.
Neoplasms of the supporting tissues in the head and neck are outnumbered by their histologic counterparts in the trunk and extremities. This is especially true for tumors of bone, cartilage, and the remnants of the notochord. Malignancies occurring in all three tissues, however, are just as lethal as those sited elsewhere. Chondrosarcomas and osteogenic sarcomas of the facial bones are resistant to all conventional modes of therapy, manifest many recurrences, and have an often protracted morbidity. The craniocervical chordoma manifests a similar biologic course. For the tumors of cartilaginous origin and the osteogenic sarcomas, the initial surgical attempt at removal is of key importance. Neoplasms present at the margins of resection have a poor prognosis. Chorodomas are not likely to be cured by any modality.
The incidence and type of x-ray semeiotics of the skull involvement were studied in 703 patients with endocrine diseases (26 with acromegaly, 36 with hypercorticism, 104 with thyrotoxicosis, 23 with hypothyrosis, 98 with primary hyperparathyrosis, 302 with diabetes mellitus, 114 with hypogonadism). Craniogram analysis involved study of the thickness and structure of the vault bones, shape and size of the skull, status of the sutures, internal plate relief, changes of the base of the skull, of the sella turcica first of all, and facial bones. The characteristic x-ray symptom complexes of the involvement of the skull in some endocrine diseases were distinguished.
The main lesions of the skull and hand, observed in a group of hypertransfused beta-thalassaemic patients, are compared with a control group of low-transfused patients. Bony abnormalities reflect the relationship between proliferating bone marrow and bone cortex, and hypertransfusion therapy will prevent development of lesions only if established early in life. If this is done, the diploë in the skull may become normal, overgrowth of facial bone is moderate, pneumatisation of the paranasal sinuses is not completely prevented, and the "hair-brush" pattern may disappear completely. A normal appearance of the hand in adequately treated patients differentiates between prepubertal patients and adults.
Yolk sac tumor (endodermal sinus tumor) is rarely encountered in the temporal bone. Facial nerve paralysis can be a primary manifestation of this condition. Histologically, the tumor can be difficult to diagnose, although elevated levels of alpha fetoprotein can facilitate its identification. In this report, we describe the case of an 18-month-old girl who developed peripheral VIIth nerve palsy and a polypoid mass in the left external ear canal 3 months following myringotomy. Computed tomography and magnetic resonance imaging revealed that the tumor involved the left external ear canal, middle ear space, and mastoid air cells. Biopsies were consistent with a yolk sac tumor. Special staining demonstrated that only a very few tumor cells were positive for alpha fetoprotein, despite the markedly elevated level of alpha fetoprotein in her serum. The patient was treated with chemotherapy, which included cisplatin, etoposide, and bleomycin. Within a period of weeks, she experienced a complete reversal of her left VIIth nerve palsy, a marked decrease in her serum alpha fetoprotein levels, and a dramatic resolution of the tumor as demonstrated radiographically. Such a successful chemotherapeutic response in this case argues against surgical intervention in other cases, particularly in view of the risk of serious complications with surgery.
OBJECTIVE: We describe the sonographic findings of nasal fracture in children, and we evaluate the diagnostic value of sonography as compared with conventional radiography and clinical findings to determine whether sonography can be a primary technique for evaluating nasal fracture in children. MATERIALS AND METHODS: Conventional radiographs and sonographic scans were obtained in 26 consecutive children with nasal trauma who were seen at our hospital from March 2003 to March 2005. There were five girls and 21 boys, and their ages ranged from 1 year 9 months to 15 years 11 months (mean age, 9.9 years). The following sonographic scans (HDI-5000 unit with a 7-15-MHz linear array transducer) were used to evaluate the nasal bone at different levels: a midline longitudinal image; axial scans of the nasal bones at the upper, middle, and lower levels; images of the nasal septum; and transverse and longitudinal scans of both lateral walls. Ten children also underwent CT. RESULTS: Conventional radiographs depicted 14 (54%) of 26 fractures. Sonographic scans were able to show all the fracture lines. One case was diagnosed as an old nasal fracture on the basis of a physical examination, even though a visible fracture line was seen on sonography. The sonographic findings of nasal fracture were disruption of the bone continuity with or without separation of the fractured segment (7/26), displacement of the bone segment as being depressed or overriding (20/26), associated septal deviation (7/26), and separation of the pyriform aperture of the maxilla and nasal bone (2/26). The associated findings were soft-tissue edema and hypoechoic hematoma near the fracture lines in 25 cases. The fractures involved both sides of the nasal bones in 11 of 26 cases, the midline part of the bones in six of 26 cases, and the unilateral paramedian or lateral part of the bones in 12 of 26 cases. Among the 10 CT scans, one CT scan did not depict the fracture, showing only soft-tissue swelling, and one scan showed fractures of the orbital floor and maxilla. CONCLUSION: Sonography can be a primary diagnostic technique for evaluating nasal fracture in children. It inflicts no radiation, provides various imaging planes without positional change, and can be used to evaluate the cartilaginous septum. Potential pitfalls are the nasofrontal suture, the junction between the nasal bone and the pyriform aperture of the maxilla, the vascular groove, and the presence of an old fracture. CT can be used in addition to sonography in cases of suspected complex facial bone trauma.
OBJECTIVE: To describe a patient with facial pain, ipsilateral facial dystonia, and phantom supernumerary teeth, beginning after resection of hypertrophic gums. She had familial sensorineural deafness. BACKGROUND: Atypical cranial dystonia subsequent to dental procedures is associated with facial pain, dysesthesias, or phantom phenomena, but not with phantom supernumerary teeth. Patients with migraine are susceptible to experience cephalic phantom phenomena after dental procedures. Wynne syndrome is a hereditary autosomal dominant disorder characterized by congenital sensorineural deafness and supernumerary teeth. METHODS: Clinical examination, computerized tomography of paranasal sinuses and facial bones, magnetic resonance imaging of the brain, cranial electrophysiological testing, and electroencephalogram. RESULTS: A 52-year-old woman with history of migraine without aura for 40 years exhibited focal right facial involuntary tonic contracture accompanying chronic severe pain over the same area after gum resection. She reported a daily sensation of having two extra upper canine teeth pressing on her tongue, simulating vampire's ("Dracula's") teeth. She had high-frequency bilateral sensorineural deafness. Her computerized tomography studies, brain magnetic resonance imaging, and cranial electrophysiological testing were normal. CONCLUSION: This patient with chronic migraine had atypical cranial dystonia beginning after a dental procedure. Her dystonia was complicated by the unusual phenomenon of phantom supernumerary teeth. This condition may be misdiagnosed as atypical or psychogenic facial pain when facial dystonia is localized or subtle and is, therefore, confused with an idiosyncratic gesture or habitual spasm. Her signs and symptoms are reminiscent of Wynne syndrome.