Injury, Int. J. Care Injured 40 (2009) 1252–1259

Review

Maxillofacial trauma—Developments, innovations and controversies

Michael Perry *

Consultant Oral and Maxillofacial Surgeon, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1252

Applied biomechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253

Mechanisms of injury and pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253

Soft tissues and fracture management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253

ATLS and facial trauma—can one size fit all? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1253

Timing of surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254

Imaging in facial trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254

Surgical approaches to the facial skeleton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1254

Repairing facial fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255

Endoscopic repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255

Controversial topics—management of the fractured Condyle56,60 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255

Controversial topics—management of frontal sinus fractures25,58,65,136 and CSF leaks24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1255

Biomaterial developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256

Secondary correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256

Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1256

A R T I C L E I N F O

Article history:

Accepted 17 December 2008

Keywords:

Maxillofacial

Trauma

ATLS

Developments

Controversies

A B S T R A C T

Despite seat belt and alcohol legislation, craniofacial trauma still remains a common health problem and

significant workload in many maxillofacial units. Although management has evolved considerably from

‘‘wiring teeth together’’, complex fractures can still result in cosmetic and functional deformity. Today’s

challenge is to consistently restore patients back to their pre-injury form and function—but this is not

always possible. Greater understanding and developments have significantly improved outcomes,

although controversy still exists in some areas. This review outlines some of these topics.

� 2008 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

Injury

journa l homepage: www.e lsevier .com/ locate / in jury

Introduction

Despite seat belt and alcohol legislation,59,78 craniofacialtrauma122 still remains a common health problem and significantworkload in many maxillofacial units.141 Although managementhas evolved considerably from ‘‘wiring teeth together’’, complexfractures can still result in cosmetic and functional deformity.

* Tel.: +44 2890 484 511.

E-mail address: mikepmaxfax@yahoo.com.

0020–1383/$ – see front matter � 2008 Elsevier Ltd. All rights reserved.

doi:10.1016/j.injury.2008.12.015

Today’s challenge is to consistently restore patients back to theirpre-injury form and function—but this is not always possible.Greater understanding and developments have significantlyimproved outcomes, although controversy still exists in someareas. This review outlines some of these topics, namely;

Applied biomechanics, mechanisms of injuries and pathophy-siology applicable to the face.Soft tissues.Advanced Trauma Life Support (ATLS) and the face.Imaging.

M. Perry / Injury, Int. J. Care Injured 40 (2009) 1252–1259 1253

Surgical approaches and repair.Endoscopic repair.Controversial areas—Timing, plate removal, condyle and frontalsinus.Biomaterials and secondary correction.

This is not an exhaustive list, but focuses on current topics andkey papers, which have shaped the management of the facialtrauma over the last 10–20 years.

Applied biomechanics

Why do we have sinuses? One controversial theory104 is thatthe facial skeleton has evolved into a ‘‘crumple zone’’, preventingimpact energy being transferred to the brain. Condylar fractures,for example following a blow to the chin, protect the brain stem.The midface can be conceptualised as a number of paired verticaland transverse buttresses, between which the sinuses lay, coveredby paper thin bone. The thicker vertical buttresses resist functionalforces (biting), while the horizontal buttresses house the organs(e.g. eyes) and define facial shape, but are relatively weak andcollapse on impact. Anatomical reduction of these buttresses isessential for the reestablishment of occlusion, facial height, widthand projection. The nasal septum is important for midface growth.

Mechanisms of injury and pathophysiology

Understanding mechanisms of injury can provide clues tooccult injuries,23,45 which can be initially overlooked.31,32,36,131

With regards to facial injuries;

1. Specific injuries may occur following facial impacts (cf the ‘‘bell-clanger effect’’ in the mediastinum). Hippocrates noted theassociation between forehead trauma and blindness74 around400BC.39 Cervical spine injuries have also been described—withupper midface injuries, cervical fractures tend to be at a lowerlevel, while mandibular fractures are related more to upperfractures.94

2. Fractures from altercations are simpler to reduce and treat, withlimited or no exposure and simple fixation. Conversely, high-energy injuries often require extensive procedures with openreduction and rigid fixation.

3. ‘‘Panfacial’’ fractures are associated with bleeding, swelling andairway compromise. These complications can also occur in theabsence of any fractures, in patients taking anticoagulants orwith clotting abnormalities.52 Retropharyngeal haematoma(high cervical injuries), can result in delayed obstruction.92

Swelling worsens when supine, from elevated venous pressuresand reduced lymphatic drainage.

4. Although laminated windscreens and airbags have reducedmortality, injuries to the periorbital region,35 globes,53 softtissues, temporomandibular (TMJ) joints64 and fracture of theposterior arches of C1 and C2 are reported associations.28

5. Bone is plastic. Localised impacts can temporarily deform thefacial skeleton. Optic nerve injury can occur following foreheadand midface trauma, in the absence of fractures. Orbital apexdisruption18 can injure the tethered nerves and vessels andresulting in blindness. Similarly blows to the cheek can result inisolated orbital floor ‘‘blowout’’ fractures.

6. Loss of sight usually occurs immediately, but can be delayed.68 Itcan also occur following apparently minor injuries, withminimal signs of injury.14,46

7. Severe hypotension has resulted in loss of sight (ischaemicneuropathy43,118,135)—in the absence of craniofacialtrauma.12,17,41 Conversely hypertension during resuscitationmay precipitate intraocular bleeding. In the elderly a dilated

pupil may precipitate ocular problems. Acute angle closureglaucoma can be precipitated by drugs13,73 and generalanaesthesia—this should be considered in any tense, painful,red eye.

Soft tissues and fracture management

The excellent blood supply to the face has facilitated thedevelopment of procedures not possible elsewhere in the body.Degloved, contaminated and infected fractures often healuneventfully following fixation,71 a situation rarely seen in thelimbs after comparable soft tissue injuries. ‘‘Free-grafting’’ 48 ispossible—bone can be detached totally from its soft tissues,manipulated and replaced,83,88 with little risk of infection orresorption. This has enabled development of extracorporal repairand access orbitotomies.33 Bone can harvested from a choice ofdonor sites70 (commonly calvarium, iliac crest, or rib). Converselycare is required in comminuted fractures where severe soft tissuedamage impairs healing. Soft tissue contraction can occur andaftercare is especially important. Careful resuspension of softtissues following degloving incisions is crucial for good aesthetics.In some areas, over reduction is desirable as a degree of contractionis inevitable.

ATLS and facial trauma—can one size fit all?

ATLS6,38,138 is generally accepted as a gold standard intrauma.30 Unfortunately the coexistence of facial injuries andinjuries below the clavicles can pose a number of clinicalproblems110,111 as each may affect the management of theother.4,37 Even potential injuries (notably spinal), can affectmaxillofacial intervention. Conversely, facial injuries may hinderthe assessment of other body regions.11 Therefore maxillofacialsurgeons should ideally be an integral part of the trauma teamwhen facial injuries are evident. Facial injuries can be broadlyplaced into four groups, based on clinical urgency.

1. Immediate life or sight-preserving interventions required.2. Treatment required within a few hours—heavily contaminated

wounds in a stabilised patient.3. Treatment can wait 24 h if necessary.4. Treatment can wait over 24 h if necessary.

Primary survey pitfalls include.

1. Airway assessment113—Direct inspection is essential. Compro-mise may arise from loose teeth, dentures, oropharyngealbleeding,132 tissue displacement, and swelling. Maintenancetechniques may be difficult with mandibular fractures. Unex-pected vomiting can occur. Senior clinical input is usuallynecessary.7,51

2. Rigid collars restrict mouth opening and with mandibularfractures can precipitate airway problems.90 They can also raisethe ICP47,76 (clinical significance unknown).

3. Life-threatening blood loss can occasionally occur. Bleeding maycontinue unrecognised over a prolonged period (e.g. scalplacerations or in supine, awake patients who swallow theirblood). Anecdotally, even ‘‘minor’’ fractures (nasal and man-dibular) have resulted in significant blood loss requiring fluidresuscitation. Midface bleeding can be difficult to control due tothe extensive collateral supply.93

4. Damage control principles126,130 may be useful as immediatedefinitive repair is not essential.112 This avoids prolongedanaesthesia and surgery in a sick patient and facilitatesresuscitation. Sequencing is important77—packing the nasalcavity displaces unsupported midface fractures. Stabilisation

M. Perry / Injury, Int. J. Care Injured 40 (2009) 1252–12591254

techniques include bite blocks, wires, splints, intermaxillaryfixation (IMF), or plating. External fixation provides rapid ‘firstaid’ stabilisation where there is tissue loss or contamination.

5. Bilateral external carotid ligation is traditionally described forpersistent bleeding.140 However, this is time consuming, haslimited success (ethmoid collaterals) and may be required in‘uncleared’ necks. Supra-selective embolisation29,89,98 isincreasingly being reported as an effective alternative.107

Multiple bleeding points can be identified34 and the techniqueis repeatable. Immediate access to facilities and on site expertiseare essential.

6. Initial assessment of the eyes3,114 and visual pathways mustconfidently exclude sight threatening injuries.9 Detailed exam-ination can be performed later. Any sight-preserving proceduresmust then be performed as quickly as possible.5,16,21,66 The mainproblem is rapidly making such diagnoses,55 as this is oftenbased on a limited clinical examination. Clinical judgement isoften necessary (e.g. ‘‘very’’ tense proptosed globe). Flash VisualEvoked Potentials (VEPs42,79,97) have been used to assess thevisual pathway, but the equipment is currently cumbersomeand not suited for the emergency room.

Timing of surgery

The best time to repair complex facial injuries in the multiplyinjured patient remains controversial. Historically, treatment wasdeferred until intracranial injuries had been managed, sometimesby many weeks. However there has been a move towards the earlyand total repair of facial injuries,22,26,63,102 often within the firstfew days50 and sometimes, hours of injury. Complex cases requirewide exposures, anatomical reduction and primary bone graft-ing.103,119 This is believed to result in much better functional andaesthetic outcomes. With long delays (around 14 days) soft tissuesbecome adherent, making repair difficult. This is particularlyimportant in the canthal region of the eye, a very difficult area tocorrect secondarily. However, this approach has to be balancedagainst the patient’s overall condition. Prolonged early surgerymay add to the ‘‘first biologic hit’’ and subsequent risk of MOF.86,130

Repair is also difficult if significant swelling is present. By delayingsurgery, swelling can resolve and further assessment, planning andpatient consent can be undertaken. The optimal time todefinitively repair facial fractures is still not known, althoughprobably varies from case to case.

Imaging in facial trauma

Computed tomography (CT) has revolutionised the assessmentof complex injuries.27,101,123 With the newer high speed scanners,CT of the face is now possible at the same time as other bodyregions,61 avoiding additional transfers and delays in manage-ment. Surgeons can now co-ordinate treatments enabling cranio-facial fractures to be treated comprehensively. CT is particularlyuseful in assessment of the skull base, orbits, sinuses and condyles.Because rapid identification of some vision-threatening injuries isessential, indications for scanning should include the mechanismof injury (cf torso injuries).106 On this basis any patient requiring abrain CT,144 who has suspected midface injuries, should alsoundergo imaging of (at least) the orbits.62,99 The following affectearly management.

1. Globe rupture.2. Optic nerve transection.3. Intraocular haemorrhage.4. Intraocular foreign bodies.5. Periorbital and orbital apex fractures.6. The nature of any proptosis (oedema, haemorrhage, air, or bone).

Removal of foreign bodies from the orbit and neck is difficultdue to limited access, altered anatomy or the proximity of vitalstructures. Image intensification and ultrasound are helpful, butCT-guided navigation systems now enable precise orientation ofsurgical instruments,133 visualised on a monitor in the operatingtheatre. Repair and reconstruction of complex orbital anatomy hasparticularly benefited from this. 3D imaging is also readilyavailable now and together with anatomical models87 enablespreoperative planning, model surgery and fabrication of customimplants, saving operating time.

MRI is sometimes used in the assessment of soft tissue changesin the temporomandibular joint67. Disc displacement, capsulartears and haemarthrosis have been reported to reflect the degree ofinjury sustained. Ultrasound has been used in the diagnosis offacial fractures, notably orbital injuries.81,105 It has also been usedto confirm reduction of zygomatic arch fractures, but haslimitations in the presence of surgical emphysema.

Surgical approaches to the facial skeleton

Internal fixation has resulted in the need for aestheticallyplaced incisions. Most mandibular and midface fractures are nowapproached through the mouth, although skin incisions (orlacerations) may be used in upper midface and some comminutedmandibular fractures. Although larger ‘‘rigid’’ fixation plates areavailable for lower mandibular border fixation, their use isdebatable as miniplates can be placed transorally and have lowmorbidity. Screws are placed transorally or via a small stab woundin the cheek (‘‘transbuccally’’)—which is best is currently also amatter of debate and surgeon’s preference. Common cutaneousapproaches include:

1. Condylar fractures—The preauricular approach139 providesaccess in high neck and intraarticular fractures. For lowerfractures, the retromandibular100/transparotid/submandibularapproaches may be used. Complications are generally rare, butinclude injury to the facial nerve and salivary fistulae.

2. Upper face (e.g. Nasoethmoid, zygoma). The traditional ‘‘opensky’’ or ‘‘seagull’’ incisions provide good exposure to the nasalbridge and medial orbits, but result in obvious scarring. Thesehave now been replaced by more aesthetic incisions. An upperblepharoplasty incision provides surprisingly good access to thezygomatico-frontal suture and lateral orbital wall and hassuperseded the lateral eyebrow incision in many units. Skinincisions are still possible over the bridge of the nose, but theseshould be placed in skin creases to minimise visible scars. Repaircan often be undertaken via incisions no more than 1 cm.

3. Orbit.15 This can be approached through the lower eyelid(transcutaneous), or via the conjunctiva (transconjunctival10).Both provide access to the entire orbital floor and lower parts ofthe orbital walls (medial and lateral) and can be extendedmedially20 and laterally. If deeper access to the posterior orbit isrequired, orbitotomy (temporary removal of the lower orbitalrim) improves this. The rim can later be replaced and securedwith a microplate.

4. Extensive craniofacial fractures.1 Access may be possiblethrough single or multiple incisions, depending on a numberof factors. The coronal scalp flap145 provides complete anduninterrupted visualisation of almost the entire upper face andfrontal region. It also allows cranial bone to be harvested,avoiding a second donor site. Potential complications includefacial nerve injury,2 diplopia, telecanthus, alopecia and scalpnecrosis.

5. Midfacial degloving.19 This has gained popularity offering goodexposure to the central part of the midface, nasoethmoid region,zygomatic region and the medial canthus without visible

M. Perry / Injury, Int. J. Care Injured 40 (2009) 1252–1259 1255

scarring. In combination with a transconjuctival incision it hasbeen used as an alternative to the coronal incision. To date theredo not appear to be any significant postoperative complicationsreported.

6. Nasal injuries. Although commonly managed by closed manip-ulation, occasionally an open rhinoplasty approach is required.

Repairing facial fractures

This has undergone considerable change over last 30 years.82

Early methods included closed manipulation, intermaxillaryfixation, dental (‘‘cap’’) splints and external fixation. Such closedmethods were essentially ‘blind’ manipulations, where the onlyguides to reduction were the bite, palpation or postoperative films.Reduction relied on fragments ‘locking’ together under an intactperiosteum. Not surprisingly these resulted in poor outcomes.Nowadays many fractures are treated by open reduction, withimproved precision, aesthetics and functional outcomes.69 How-ever ‘‘panfacial’’ fractures are still extremely challenging. Adequateaccess and correct sequencing are essential to restore facial height,width, projection and the occlusion. Particular attention isrequired in the posteromedial orbit and inner canthal region –both are key to good aesthetics. IMF is still used in some mandiblefractures, although this is mostly in minimally displaced andcondylar fractures. Its principle is simple: if the teeth are secured inocclusion the fractures will be adequately reduced and stabilized.Elastics are now commonly used, rather than wires. However IMFis difficult to use in pre-existing malocclusions, missing, loose ordamaged teeth. Attached muscles may still displace the bonyfragments. Vomiting can also be difficult to manage.

Plates are available in different sizes, depending on the amountof support required across a particular fracture site. Both ‘‘loadbearing’’ and ‘‘load sharing’’ fixation systems have been developed.Load bearing is possible where there is substantial bone present tosupport loading across bicortical screws, notably in the mandible.Both screws and plates are, by necessity, large and need to beremoved, although patients can fully function very soon afterfracture repair. ‘‘Miniplates’’ are small and can be left in situ. In themandible the tension band principle is used.40,75 Consequentlythey can be secured with small monocortical screws, which can besafely placed over dental roots and the inferior alveolar nerve.‘‘Fine tuning’ of the occlusion is possible using elastics and archbars. Self-drilling screw are now available. ‘‘Microplates’’ andscrews are used to repair small or thin fragments (frontal sinus,orbital rim and nasal bones). This has led to novel uses in laryngealfractures.80

Routine removal of these devices is debatable. Stress shieldingis minimal and concern centres on how ‘‘inert’’ titanium reallyis.85,121 Release of titanium into local tissue and particle migrationto the lungs is well documented.137,142 Allergy and potentialcarcinogenic effects have also been raised. Nevertheless thegeneral consensus is that titanium is much more stable thanother alternatives currently available.

Endoscopic repair

Endoscopy is widely used in craniofacial surgery and increas-ingly so in trauma.49,91 Compared to conventional techniques itresults in less tissue damage, complications and shorter recovery.Common indications include:

1. CSF leaks (controversial).2. TMJ arthroscopy (diagnostic and therapeutic).3. Condylar fractures.96,127,128

4. Isolated anterior frontal sinus fractures.143

5. Selected midface, orbital floor and zygomatic arch fractures.

6. Endoscopic control of epistaxis is well described,57 but of limiteduse in pan facial fractures where multiple bleeding points arepresent. Currently these techniques are best used in localisednasal injuries.

Controversial topics—management of the fractured Condyle56,60

Condylar fractures are common and account for up to half ofall mandibular fractures. Controversy still exists over manage-ment in ‘‘adults’’ (patients over the age of 12). In childrennonsurgical ‘‘functional’’ treatment results in good outcomesas condyles can regenerate and remodel.72 Even fracture dislo-cations can be successfully managed this way. However inadults incorrectly treated fractures can lead to significantfunctional impairment—dysocclusion, restricted and deviatedmouth opening.

The role of open reduction is controversial. Functional IMF stillproduces acceptable results,8 bony union and complications arerare. However many surgeons now believe that modern techniquesand surgical experience carry minimal risks and produce betterlong term results. Pain, clicking and (in the growing face),asymmetry are also said to be less likely. Rehabilitation is quicker.Current indications for open reduction include failure to restorethe bite with closed reduction, displacement of the condyle intothe middle cranial fossa (a rare complication) or laterally, and anoverlying open wound with foreign body. In bilateral cases it hasbeen recommended to repair at least one of the condyles,effectively converting the patient into a ‘‘unilateral’’ fracture,which is easier to manage. ‘‘Free-grafting’’ of the upper fragment(either alone or in combination with a posterior ramus osteotomy),is occasionally required.

Controversial topics—management of frontal sinus fractures25,58,65,136

and CSF leaks24

This complex anatomical area should always be consideredalong with nasoethmoid fractures, as bone fragments maydamage the frontonasal duct (FND). Fractures often followhigh-energy impacts and therefore may be associated withintracranial, cervical and ocular injuries. However patients canalso present in relatively good neurological condition, in keepingwith the ‘‘crumple zone’’ theory. The management of frontal sinusfractures is controversial and undertaken by several surgicalspecialities. Complications are potentially very serious andmostly occur with displaced posterior wall fractures. Mostcomplications occur within the first 6 months but there is alife-long risk of others—mucocele, mucopyocele, and brainabscess have all been reported 50 years following injury.108

Other complications include osteomyelitis, meningitis,44 CSFleakage, headaches, and cosmetic deformity.

CT has greatly facilitated assessment and treatment planning.Original treatments involved exenteration of the sinus allowingthe overlying skin to collapse onto the dura thereby preventingmucus collection and secondary infection. This was later modifiedby preserving the supraorbital rims in order to improve cosmeticappearances. Today, the aim of surgery are to create a ‘‘safe sinus’’(isolate and protect intracranial structures, stop cerebrospinal fluidleakage, prevent complications), and restore facial aesthetics. Howthis is best done falls into three main camps—sinus obliteration,cranialisation and reestablishment of anatomy and drainage. Manyprotocols and procedures exist, but as yet there is no unified,evidence-based approach to these complex injuries. Long termfollow up and hence long term critical evaluation of these variousstrategies is very difficult. Access often involves a bicoronalapproach enabling craniotomy and the use of pericranial flaps.Post-operatively valsalva maneuvers such as nose blowing, closed-

M. Perry / Injury, Int. J. Care Injured 40 (2009) 1252–12591256

mouth sneezing, or strenuous activities must be avoided. Generalprinciples include:

1. Nondisplaced fractures of the anterior table with no FNDobstruction should be treated nonoperatively.

2. Displaced isolated anterior wall fractures can be repaired orsecondarily reconstructed.

3. Management of complex injuries depends on the presence offrontonasal duct injury and dural tears.

4. Sinus mucosa must be meticulously removed and the bonescarified with burrs to remove residual mucosa.

5. Sinus obliteration120—the sinus is obturated with a number ofmaterials.84 Autologous bone, fat, pericranium and muscle aresafe but can resorb. Synthetic materials (acrylic resin, Gelfoam,and bone pastes) have also been used but are at risk ofabsorption, infection and extrusion.

6. Cranialisation of the sinus—the posterior wall of the sinus isremoved, dura repaired and the intracranial contents isolatedfrom the nose by obturating the FND. This approach is morecommonly undertaken in the presence of persistent cerebrosp-inal fluid leakage.CSF leaks are uncommon and usually resolve without surgical

intervention. Confirmation requires testing for the presence of b2transferrin, as glucose levels and the ‘‘target sign’’, or ‘‘ring test’’ arenot reliable. Antibiotics are not recommended, due to acquiredresistance. Initially leaks are observed for 7–10 days, followed byCSF diversion (lumber drain) for 5–7 days. If repair is requiredhigh-resolution CT or intrathecal fluorescein are needed to identifythe site of leakage. Repair can be performed either intracranially,extracranially or endoscopically and falls outwith the remit of thisreview.

Biomaterial developments

Although titanium is not the ideal material it has been used forover a decade, due to adequate biocompatibility and mechanicalproperties. Contact with the dura does not seem to produce clinicalproblems. However particle migration, local reactions, thermalparaesthesia, and interference with CT scans have led to the searchfor more biocompatible materials and in some units there is now atrend towards the use of bioresorbable materials. Research is alsoongoing into the development of a ‘‘bone glue’’. Various polymershave been developed which degrade by hydrolysis into water andcarbon dioxide. Resorbable fixation is now well established inchildren, particularly in the skull, where passive migration of metalplates occurs during growth. However biodegradable screws haveless mechanical stability and swelling of the plates occurs duringdegradation. Tapping is sometimes necessary. Ultrasound-aidedpin fixation115 is a relatively new means of osteosynthesis. Insteadof screws, a pin is inserted into the drill hole using an ultrasoundstimulated melting (welding) process. The pin liquefies and flowsinto the trabecular bone as well as welding to the plate. Pins can beinserted at different angles, torque forces are avoided, and there isno need for tapping.

Materials commonly used95,117 (more for secondary recon-struction than primary repair) include:

1. Silicone.2. P.T.F.E. (polytetraflurorethylene).3. Hydroxyapatite and other ‘‘bone source’’.4. Medpore (porous polyethylene54).5. Titanium129.

Bone morphogenetic proteins116,124 (BMPs) have also receiveda lot of interest in the restoration of bony defects, although they arecurrently not used widely.

Secondary correction

One of main challenges in maxillofacial trauma is to consistently

restore patients back to their pre-injury form and function. Despitethese advances and developments the harsh reality is that in asignificant number of patients we still fall short of this standard.This is more likely following high-energy trauma (comminutedfractures and severe soft tissue injury), where treatment is delayed,or complications develop. Secondary correction may then berequired. This has also benefitted from many of the samedevelopments.

Crudely speaking tissues can be considered as missing (avulsioninjuries), excessive (hypertrophic scars, residual callus) ordisplaced (nonanatomical repair). This simple approach helpsplan treatment. Detailed clinical assessment involves determiningboth functional and aesthetic problems. This can be supplementedwith imaging usually CT. In addition to films, dimensionallyaccurate 3D models can now be fabricated109,125 Stereolithogra-phy134 and laser sintering are processes where model are madefrom liquid light-cured monomer or plastic powder. Osteotomiescan then be performed, plates pre-bent and implant size andshapes determined. By inverting images and using subtractiontechniques the difference between injured and non-injured sidecan be calculated and custom implants fabricated without the needfor models. Computer-assisted guidance facilitates exact place-ment of these preformed implants through smaller incisions with areported accuracy of 1 mm. This is particularly useful in orbital andcranial reconstruction. Unfortunately there are still limitations.Metal and motion artefacts, partial volume effect and shrinkage ofthe resin can contribute to inaccuracies. Reconstruction ofcombined bone and soft tissue deformity is difficult due tounpredictable soft tissue changes. New algorithms for soft tissuereconstruction may solve these problems in the future.

Reconstruction of soft tissue defects is generally more difficultthan bone as soft tissue contraction increases the risks of relapse inposttraumatic correction. A number of techniques are available(e.g. injection of bone substitutes, onlays, or implantation of fat andfree tissue transfer). These are extremely technique dependent.

Summary

The management of the injured face has undergone majorchanges following greater understanding of the healing processand with advances in technology. Outcomes are considerablybetter than 30 years ago as more comprehensive assessment andmanagement is now possible. Nevertheless the goal of consistentlyrestoring patients back to their pre-injury form and function stilleludes maxillofacial surgeons as in both our patients, andourselves, expectations have subsequently increased.

Conflicts of interest

None.

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