Trauma and Reconstruction, An Issue of Oral and Maxillofacial Surgery Clinics (eBook)

David S Precious (Autor)

eBook Download: EPUB

2013 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-26115-9 (ISBN)

Infos

An important review on trauma and reconstruction for the oral and maxillofacial surgeon! Topics include systematic assessment, imaging for diagnosis and management, helping anesthesiologists understand patients with facial fractures, management of fractures of the condyle, condylar neck and coronoid process, mandibular angle, body and symphysis, zygomatico-maxillary complex, naso-frontal complex, pan-facial complex, late reconstruction of condyle and condylar neck fractures, orbital and naso-orbital deformities, residual soft tissue deformities, and more!

Textauszug

Responsible and Prudent Imaging in the Diagnosis and Management of Facial Fractures

Savannah Gelesko, DDS, MDa∗[e-mail], Michael R. Markiewicz, DDS, MPH, MDa and R. Bryan Bell, DDS, MDbcd,     aDepartment of Oral and Maxillofacial Surgery, Oregon Health and Science University, Mail code: SDOMS, 611 Southwest Campus Drive, Portland, OR 97239, USA; bOral, Head and Neck Cancer Program and Clinic, Providence Cancer Center, Providence Portland Medical Center, 4805 Northeast Glisan Street, Suite 6N50, Portland, OR 97213, USA; cTrauma Service/Oral and Maxillofacial Surgery Service, Legacy Emanuel Medical Center, 2801 North Gantenbein Avenue, Portland, OR 97227, USA; dOregon Health and Science University, Mail code: SDOMS, 611 Southwest Campus Drive, Portland, OR 97239, USA

∗Corresponding author. Department of Oral and Maxillofacial Surgery, Oregon Health and Science University, Mail code: SDOMS, 611 Southwest Campus Drive, Portland, OR 97239.

This article reviews the current standard of care in imaging considerations for the diagnosis and management of craniomaxillofacial trauma. Injury-specific imaging techniques and options for computer-aided surgery as related to craniomaxillofacial trauma are reviewed, including preoperative planning, intraoperative navigation, and intraoperative computed tomography. Specific imaging considerations by anatomic region include frontal sinus fractures, temporal bone fractures, midfacial fractures, mandible fractures, laryngotracheal injuries, and vascular injuries. Imaging considerations in the pediatric trauma patient are also discussed. Responsible postoperative imaging as it relates to facial trauma management and outcomes assessment is reviewed.

Keywords

Maxillofacial trauma • Computer planning • Navigation • Computer-aided surgery • Facial fracture

Key points

• Every effort should be made to optimize treatment outcome during the initial operative treatment.

• Judicious use of computed tomographic (CT) imaging is required, tempered by the potential risks associated with repeated radiation exposure.

• Until optimal radiation thresholds are established, the surgeon must use their best judgment, in consultation with an informed patient, to obtain enough preoperative, intraoperative, and postoperative data.

• Computer-aided surgery, utilizing preoperative planning, intraoperative navigation, and intraoperative CT scanning, appears to favorably improve outcomes in the treatment of complex posttraumatic craniomaxillofacial deformities.

Introduction

The past century has seen a dramatic change in the type, quality, and method of diagnostic imaging techniques used for craniomaxillofacial traumatic injuries. This article systematically reviews the current standard of care in imaging considerations for the diagnosis and management of craniomaxillofacial trauma. In addition, injury-specific imaging techniques and options for computer-aided surgery as related to craniomaxillofacial trauma are reviewed, including preoperative planning, intraoperative navigation, and intraoperative computed tomography (CT) scanning. Specific imaging considerations by anatomic region include frontal sinus fractures, temporal bone fractures, midfacial fractures, mandible fractures, laryngotracheal injuries, and vascular injuries. Imaging considerations in the pediatric trauma patient are also discussed. Responsible postoperative imaging as it relates to facial trauma management and outcomes assessment is reviewed.

Computer-aided surgery

Virtual, or computer-aided, surgery encompasses 3 forms of computer-assistance for the maxillofacial surgeon: (1) presurgical planning, (2) intraoperative navigation, and (3) intraoperative CT scanning.

Virtual surgery can be divided into 4 broad phases: (1) data acquisition phase, (2) planning phase, (3) surgical phase, and (4) assessment phase. These phases are modified based on which maxillofacial procedures are being performed. In this article, each phase is reviewed with regard to the treatment of maxillofacial trauma. A thorough discussion on implementing virtual surgery into practice with a step-by-step case review of a panfacial trauma case has recently been described by our institution.1

Data Acquisition Phase

A careful clinical examination is an essential portion of the data acquisition phase, because the bony evaluation must be balanced with the soft tissue, focusing on the character of the tissue and any traumatic defects, as well as the dentition, which plays a large role in establishing final occlusion and reduction of most maxillofacial injuries involving the maxilla and mandible. In terms of imaging for maxillofacial trauma, high-resolution CT (HRCT) scanning is imperative, because low-resolution CT scans offer a poor representation of the thin-walled orbits and paranasal sinuses. The HRCT scan data are taken in DICOM (digital information and communications in medicine) format. These DICOM data are then imported into a proprietary CAD-CAM (computer-aided design, computer-aided manufacturing) software program. The investigators recommend choosing a proprietary software program that allows for back-conversion, discussed later, which is essentially the opposite of the initial data translation from DICOM format to the virtual proprietary software format.

Presurgical Planning Phase

The presurgical planning phase consists of analyzing the newly formatted CT data in 3 dimensions, segmenting out the traumatized portions of the facial skeleton, and using the mirror image of the unaffected side to overlay the defected portions of the facial skeleton. The planning phase differs greatly depending on the portions of the maxillofacial skeleton that are deformed and the type of reconstruction planned.2 For instance, in orbital fractures a critical measure of successful reconstruction is restoration of orbital volume, whereas in isolated zygomaticomaxillary complex fractures, successful reconstruction is largely based on restoration of bizygomatic width and facial projection, and in comminuted mandibular fractures, restoration of dental occlusion as well as mandibular width are key goals. In general, the mirror image of the unaffected side, or standardized measurements, can be used to segment out the fractured portions of the facial skeleton and plan the reconstruction. This portion of the surgical planning can either be performed by the surgeon, or as is our preference, a Web meeting can be set up with the proprietary software company, in which a computer planning specialist assists the surgeon in manipulating the CT data for the planned reconstruction. Once the surgical plan is finalized, the proprietary software data plan should be back-converted. Back-conversion specifically refers to translating the surgical data plan created by the proprietary software back to the standard DICOM format. This DICOM format may then be viewed on work stations not loaded with the proprietary software, and it allows interoperability between the planning software and intraoperative navigation systems.

Surgical Phase

During the surgical phase, the virtual surgical plan is translated to the patient using a combination of stereolithographic models, cutting guide stents, or intraoperative navigation (Fig. 1). Stereolithographic models are particularly useful for severely comminuted fractures and panfacial fractures, because they allow for preoperative plate bending and decreased time in the operating room. Cutting guide stents in maxillofacial trauma surgery are most useful in the secondary reconstruction of posttraumatic deformities, and less useful in the acute setting, in which the bones can still be mobilized for adequate reduction. Intraoperative navigation is particularly useful for real-time assessment of facial width and projection when repairing zygomaticomaxillary complex fractures, and for evaluation of plate placement during repair of orbital floor and medial orbital wall fractures.3

Fig. 1 Computer planning, navigation, and intraoperative CT scan to aid in treatment of a self-inflicted facial gunshot wound: (A, B) three-dimensional (3D) reconstruction of initial high-resolution CT scan taken in DICOM (digital information and communications in medicine) format on initial presentation. (C) 3D CT scan after being imported into the proprietary software with segmentation of the fractured preoperative anatomy, and simulated fibular free flap reconstruction. (D) Mandibular cutting guides. (E) Fibular cutting guides. (F) Simulated fibular reconstruction of the mandible with custom plate. (G) Preoperative planning for second-phase surgery with preoperative fibular reconstruction of mandible and simulated fibular reconstruction of the maxilla.

Assessment Phase

The assessment phase has historically consisted of clinical examination with or without conventional postoperative CT imaging. Now, this...

Produkt-Details

• Erscheint lt. Verlag: 1.2.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Gesundheitsfachberufe
• Themenwelt: Medizinische Fachgebiete ► Chirurgie ► Ästhetische und Plastische Chirurgie
• Themenwelt: Medizin / Pharmazie ► Zahnmedizin ► Chirurgie
• ISBN-10: 0-323-26115-9 / 0323261159
• ISBN-13: 978-0-323-26115-9 / 9780323261159