Hello and welcome! We have prepared an exciting session for you. Before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming and video recordings. Also, please note that this session has a corresponding forum discussion taking place right now on the PSTM 23 conference platform. If you have questions for our faculty, please feel free to submit them there. Please note that chat records may be recorded. Thank you for your participation and enjoy! Good morning! My name is Anand Kumar and I'm a pediatric plastic surgeon and craniofacial surgeon in Savannah, Georgia. I also am a professor at the Mercer College of Medicine in Georgia. Thank you for joining us for the Ballistic Cranio-Maxillofacial Injury panel. I think we're having a very exciting topic to discuss that is relevant to anyone who is caring for patients with acute facial injury. Before we get going, I'd like to read a brief statement regarding the copying and distributing of this content. So, before we begin, we want to remind you that the material shown here is the property of ASPS or the presenters. Copying or distributing the content in these presentations without specific consent from ASPS is prohibited, including screenshots, photography, live streaming, and video recordings. Also, please note that the session has a corresponding forum discussion taking place at the meeting on the conference platform. So, if you have questions for our faculty, please feel free to submit them there. Please note that the chat records may be recorded. Thank you for your participation and enjoy! So, today I am the moderator, again, Anand Kumar. I have three panelists with me who are experts in ballistic missile injury to the face and craniofacial skeleton. The first is Edward Davidson at Case Western University. The second is Srinivas Srinivasasurla at the University of Washington and Michael Golinko at Vanderbilt University in Tennessee. Each will be presenting a unique perspective on facial trauma, and together we hope to provide you a framework on how to address these very complex injuries that can be very challenging. Edward will be discussing general timing, sequencing, and philosophies of approach to facial ballistic missile injury. Srinivas will specifically be discussing how to use a maxilla, mandible, and occlusion-based paradigm for reconstruction, and Michael Golinko will be concentrating on the midface and reconstruction, including the orbits. So, with that, let's get going. My component of the talk will really be on management of penetrating cranial trauma, which is usually concurrent with massive facial injury that can be truly craniofacial. A lot of these techniques we developed during our time in the military, myself and another surgeon named Raymond Harshbogar, who was my Army counterpart. We used quite a number of techniques, including intracranial free flaps and cranial bone graft, to reconstruct the cranium, skull base, and prepare the field for later facial reconstruction in order to really create a framework. Many times these patients with critical neuroinjury preclude the ability to fix the face early, and so this is sort of looking at it from a top-down perspective, and you'll see from my other colleagues looking at it from the bottom up and from the sides or orbit. So I think there's many different ways to do this. So let's focus really on the cranium and the upper orbit area. So here are my relevant disclosures. And so let's talk really about the history of modern combat craniofacial reconstruction. Because that's really what reconstruction after decompressive craniectomy is about, some technical considerations in anatomy and, of course, algorithmic treatment to really high-risk cases. And so our experience during the global war on terror really moved from, as you can see, during World War I, World War II, Korea, and Vietnam, a really stagnant growth in craniofacial reconstruction in terms of the cranium. At that point, aggressive brain debridement was the norm, and obviously the devastating neurological outcomes really were quite nihilistic, and most people would recommend nonoperative treatment. So really during Operation Iraqi and Enduring Freedom, the Iraq and Afghanistan conflicts after 9-11, really shifted our focus, and particularly our combat neurosurgeons, to move away from aggressive debridement but aggressive decompression, which has now filtered its way into civilian practice. So many of you at trauma centers see patients with decompressive craniectomy with really devastating craniofacial injuries. So this will be a nice segue into how do we manage the cranium, because often that has to be addressed first or later in a delayed fashion prior to reconstruction of the face in order to prevent, of course, CSF leak, which is our devastating complication. So we recommend conservative debridement and, of course, watertight dural closure. So the reason why this was able to occur and why we're benefiting it now nearly 20 years later from the Iraq conflict is that the time from injury to neurosurgical intervention has decreased to less than one hour, which obviously has very relevant meaning to civilian practices where long distance of travel, except for the most rural parts of this country, are less than an hour. And then there are typical blast injury patterns, either from blast or ballistic missile injury, where often there's frontofacial injury, missing orbital bar, associated cerebrovascular injury, and often a decompressive craniectomy performed by the neurosurgeons before we're even seeing the patient. And this is all going to ultimately need a complex reconstruction. So when we look at this type of patient, this is sort of what we're dealing with, right? That's a craniofacial ballistic and blast injury. And obviously, interestingly enough, these patients will often have major heterotopic ossification in their extremities later on. So these large decompressive craniectomy defects and contralateral injury are common. We'll see these often in large trauma centers. And the problem is that cranial bone graft sites are limited. And many times, you may not want to go to the contralateral or both sides just due to the residual brain injury and the risks associating with this type of harvest. Now, when we were early on in our experience in warfare reconstruction, we were banking quite a bit of the decompressed bone in the hopes of later using it. And what we identified was due to the penetrating nature of injury, the heavy levels of contamination, which is often seen in civilian injury, there's a high degree of infection, which necessitates removal of the bone flap or later significant osteolysis of the bone graft that's been placed after decompression, which basically precludes its use and later switching out to a different way of managing. So what did we used to do? Well, LG Kempe wrote about his seminal experience in 417 patients at the neurosurgical service at Walter Reed. And this is really his post-Vietnam era work. And we identified that there was high success and low infection rates, but he often operated on these patients after one year, right? And we're talking about acute missile injury. How are we going to manage these patients? Well, today, we'll decompress the patient, obtain CSF watertight closure, and then address the front orbital bars and the craniofacial skeleton in a more delayed fashion within that hospitalization and then later come back for the cranioplasty. And if you're not planning on being back in the face or communicating the cranium with the oral cavity, a cranial reconstruction using a PMMA implant or other preferred alloplast is perfectly acceptable, and we've demonstrated this over time. We used our Bethesda protocol. We published this, and this is sort of not new news anymore, right? But interestingly enough, we were able to decrease cranioplasty time to within six months of the injury as opposed to a year. And in really low-contamination injuries or favorable wound beds, within three months can be acceptable. I do think having a normal UA, ESR, and C-reactive protein is a good surrogate to understand that you have control of inflammation prior to any type of alloplastic reconstruction. And so this is sort of what we typically did, a layered closure. We looked back at our results. We published this in the past, and we did almost 100 craniectomies, most of them hemicraniectomy reconstructions and a few bifrontals. We had a very high rate of success and very low, low rates of infection. And as you can see, we had some patients that had infection, hematoma, a few seizures, but a large percentage with contourebromalities. And so we published this early result, but associated really two high variables. And this is where this really comes into play in craniofacial reconstruction because the frontal orbital bar, the sinuses, are very important regarding reconstruction and separating the brain cavity or brain box away from the subcranial components and decreasing the risk of infection. And so endocranial dead space and loss of the frontal orbital bar and therefore communication with the sinuses is of high risk. So obviously this type of reconstruction is not very desirable as you are docking the entire frontal orbital space right next to the face, and obviously this patient ended up with a high rate of infection. So what about endocranial dead space? So after the acute brain injury is swollen and this is resolved, you can see here a significant contrairregularity and even worsened with this occipital base shunt. And can we treat these patients, you know, looking back at it? And I really like this panel because the decisions made in the acute injury phase are really what are going to drive the reconstructive algorithm in the acute, the subacute, and the chronic phase. So the choices you use now, meaning harvesting bone or reconstructing the frontal orbital bar, and then later reconstructing with an alloplast, is a much safer route than trying to reconstruct everything with an alloplast with it adjacent to the sinus. So this is a type of soft tissue interposition, right? Ballistic missile injury, transfacial gunshot, transcranial with a ocular injury. And this patient actually presented with CSF ocularia. As you can see, there's a large frontal cyst, an infected mesh plate placed at the skull base with communication into the enucleated right orbit and obviously a huge risk for infection. And so let's look at our plan. We're going to do a level one skull base approach. We're going to remove the mesh, cranialize residual frontal sinus, bone graft, frontal cyst fenestration, and interpose a free flap since there is in fact no tissue left from the previous pericranial flap that's already been used. So here's how this looks in the operating room with the exposure after coronal exposure. Removal of the frontal orbital bar, back table cranialization, removal of the colonized and mucosalized mesh. And then as you can see here, looking downward, we're going to place cranial bone grafts. And you can see where the two nasal frontal ducts are going into the ethmoidal region. And we're going to pack these with muscle plugs followed by bone graft and then an additional free flap. As you can see here, we chose an ALT adipofascial free flap. And I typically like to hook these into the STA. Every now and then you may need a vein graft to move into the facials if their STA was cut during the coronal exposure. This is placed. I tend to not, particularly if the flaps are large or there's a huge amount of space, I tend to leave an area open to allow the area for decompression for post-surgical swelling and prevent herniation. Often I'll also ask the neurosurgeon to place a CSF drain either in the ventricle or in the lumbar space based on their preference in order to be able to control some of that space post-operatively, limit leakage, and of course adjust if there's increased intracranial pressure. And so this is what this sort of looks like as an intermediate stage reconstruction and then after his implant. And as you can see, a lot of contra-irregularities. And this is an area of additional controversy where secondary reconstruction with fat grafting or alloplast are options. So let's look at contra-irregularities. I happen to see a fair number of patients with this pseudotosis kind of appearance after a temporalis malposition. I happen to like temporalis muscle repositioning prior to any type of alloplast or fat grafting. And as you can see in the prior slide, an excellent result with the pseudotosis corrected. Here's an example where a patient wanted a more limited approach with some fat grafting as camouflage. Now, high-risk cranioplasty, front orbital bar is missing. Here, in a delayed fashion, you can split this bone once you know you have control and there's no hemispheric injury. You can split, reconstruct, protected bone regeneration, and then get a reasonable result. And then how about endocranial dead space? Well, obviously, any time you predict when you raise that skin flap, you're gonna have greater than two centimeters and you have soft, pliable dura. Obviously, dural tack-ups are the way to go. But if you notice that there's significant scarring or a shunt, you're going to have to interpose soft tissue because if you try to place a suture through that dura, it will immediately cut and sieve right through and you'll have a CSF leak. And obviously, if you're less than two centimeters, it's cranial reconstruction of your choice. So let's look at this complex patient. This is a patient with a transhemispheric penetrating injury and a patient I saw after I left the military. So this is not a battlefield injury and you can see the severe decompression and over-shunting associated with a suboccipital shunt. I mean, it's just egregious. So stage one, let's apply our principles. Let's start addressing endocranial dead space. I used a scapular subsystem flap with a parascapular skin island and a large latissimus muscle paddle for obliteration of dead space. In this case, I hooked into the facial vessels and then did a external jugular vein turn-up, as you can see, for venous outflow. This is a good strategy when you're addressing patients with multiply-operated necks and temporal regions, period. And then you can really see here the flap inset, the skin paddle. But as you can see, this doesn't really address the rigidity of the bone in the syndrome of the trefvine, but it does allow me to have tissue to then create some planes to work with. So then stage two, we're gonna harvest some bone and reconstruct. And by the way, this patient's had five failed cranioplasties prior to seeing me. And so we're gonna split. This is what this looks like. And there's the latissimus flap. See, it's in place, but it's really decompressed because of the over-shunting. And so we're gonna place our split cranial bone grafts after harvesting and tacking up with the flap now, right, instead of the dura. And you can see we can use these with large 2-OPDS sutures and actually get a pretty reasonable head shape and reconstruction and protected bone regeneration on the side. And so this is what this looks like after this intermediate stage. Now, what happens, though, is you're gonna have some contour irregularities after this many-reoperative flap opening, as well as bone lysis. And this is what you're gonna expect to see a little bit later. So now we're gonna have to go back through the same incision, harvest every other rib, and then do split rib reconstruction to reinforce the side areas. And in addition, more allograft bone graft, soft tissue reinforcement with some alloderm. And now we're starting to get some improved contour. Now we're gonna go through a series of machinations. We're gonna remove the skin island. We're gonna add some additional allograft bone and some soft tissue with additional alloderm. And you can finally achieve this type of reconstruction after about five total procedures, which is quite remarkable considering where we started. Same situation, large endocranial dead space. Cranial implant followed by an ALT flap on the outside, but not really appreciating early in our experience of endocranial dead space. Here we are post-procedure with a massive infected epidural space infection, right back to where we started, but now with a free flap externally. Free latissimus, which is just hooked to the pedicle of the ALT flap prior end to side. And then cranial bone grafting. Then you can see here a much better improved CSF space despite not touching the shunt, right? So once you start getting rigidity of the cranium, the CSF space starts to function a little bit better and we're able to get a more reasonable reconstruction. So when we look at our bifrontal craniectomy and hemicraniectomy reconstructions, high risk, you can see, you know, the majority of patients do not need algorithmic reconstruction implant or split cranial bone graft, but these high risk cases can be adjusted and treated using our algorithm. And, you know, a fair number need free flaps, cranial bone graft, or combined cranial bone grafts and free flaps. And you can see our high risk cranioplasty failure rate went from 54 down to 8%. It's not zero, but significantly improved. But just remember, these patients can often have devastating neurological outcomes and working within a team and having a good rehabilitative team will be critical to achieving really great outcomes. I think Dr. Davidson will talk a little bit more about comprehensive team and life after facial injury programs. So we published our results as we had talked about, and obviously a hybrid reconstruction and stage sets the operative field for later work in the subcranial space. So protected bone regeneration we talked about, definitely smaller areas we can reconstruct, but larger areas there are plagued with otolysis. So here you can see stage one reconstruction and improvement, and now we can start to work on the subcranial components like the eyelid. And obviously heterotopic ossification is a huge issue. We're always hoping to use these. these in animal models to try and regenerate bone. This is an area of active research I've published in and something we can look forward to in the future for regenerative cranioplasty. And we published this in PRS some years ago. And hopefully, someday we'll translate these into the human and avoid the alloplastic issue altogether. So in conclusion, obviously, hybrid reconstructions are not a bad option when you're thinking about a frontofacial or transcraniofacial injury from penetrating ballistic missile injury. I hope I've given you some strategies on how to think about the patient acutely in terms of CSF space control, frontal orbital bar reconstruction, and coming back later for a cranioplasty after you've then addressed the subcranial components of the face, which you'll see my other panelists will be discussing. So we look forward to talking about this as a panel and giving everyone our perspectives. This is, the patients with these types of injuries are not going to be a simple, single operation and fixed. They will require a staged and thoughtful approach in order to prevent infection of any alloplasty placed if you have to come back secondarily and knowing when does communicate or not communicate the cranium with the craniofacial skeleton. Hi, everybody. My name is Michael Galento, I'm a craniofacial plastic surgeon down in Nashville at Vanderbilt and proud to be part of this esteemed panel with ASPS this year, along with my colleagues around the country. My part specifically will be dealing with ballistic trauma of the orbit to the mid face and we'll put everything together for you, highlighting a couple of cases and a couple of pertinent tips, pearls, and also raise some questions, hopefully stimulate some discussion at the end. My disclosures are I am a AOCMF faculty member and we received some department educational support from KLS Martin. All patients have given immediate consent. Certainly no talk in facial trauma would be complete without an homage to our CMF trauma mentors and friends, including Dr. Paul Manson, Dr. Zide, Big Joe Gruss in Seattle, the late Joe Gruss, and my friend and mentor to this day, Joe Williams or little Joe. So we're gonna start with some general principles and permanent anatomy of the trauma to the mid face and orbits that we're talking about. Obviously just a brief broad level review. We're gonna be discussing obviously the orbital bones, the maxilla, the zygomas, the dentition from a skeletal standpoint, and the nose and the palate. From the soft tissue affected in that same skeletal region are obviously the globes, the medial and lateral canthi, the lacrimal complex, the nose, parotid lips, and the heart and soft palate. These are just by way of comparison. Obviously we're all familiar with our medial floor and our orbital floor defects, which are typically from a single kind of blunt injury, not the ballistic injury that we'll be talking about. We'll be going over some things much more complex than these things, but this is the example of where we're talking about the anatomy. What is involved in ballistic trauma typically is an NOE fracture. Just to review, this is this area of that confluence of the nose, the ethmoids, more posteriorly of the frontal sinus and the anterior corneal base. The Markowitz classification is in three types. Type one, again, is a single large fragment with the medial canthal tendon attached. Type two is a comminuted bony segment, but that medial canthal tendon is still intact. And type three is where it's comminuted and the tendon is just completely off. I remember Dr. Ogross seeing him give talks saying this is a much more rare scenario and we said you would need a very sharp injury to really kind of take off and not bolst that tendon, but it does happen. This is a close-up view pretty much taken from the web of how that canthal complex intersects with the lacrimal sac to kind of help with the tear mechanism. Just take some examples of the other skeletal areas that we're dealing with. Obviously, facial projection is involved with the zygoma. A typical example you see here, posterior sinus wall. The maxilla can come in a lot of different shapes and sizes in terms of the L4-1 type fracture. And obviously, L4-2 type fracture is a more perimetal bone fracture where the nasal frontal process is involved and the mid part of the rims and obviously the pterygoid plates as well where there's maxillary mobility. L4-3 is a corneofacial disjunction which you can certainly see in ballistic trauma, although it's usually a mixed pattern is what you more typically see. And it involves the zygomatic arch, the nasal frontal junction completely, the zygomatic or frontal suture, and of course that pterygoid maxillary buttress behind the tuberosity of the maxilla. The hard and soft palate is sometimes overlooked just because there's so much going on in ballistic injury, but obviously just to review, you have your palatine bone over here which seats the dentition with the two transverse sutures and midline palatine suture as well. And obviously the soft tissue musculature once you end the hard palate, obviously what's important for speech is the levator butyl palatine and the other associated musculature, but the levator is the most important one. So just from acute management, we broke this up into a little bit of talking about the acute management of ballistic injury and a little bit about what those things that we may see either if we treated them or if they come to us from another center of how to treat some of the more common and more challenging secondary injuries. So obviously critical care is number one in any ballistic multilevel trauma injury. Early consideration of establishing a stable airway, be it a trach. Some mental intubation is a great tool to avoid a trach if they're otherwise a higher GCS sort of patient that wouldn't need long-term tracheostomy care. And obviously a route to be a nasal feeding or gastrostomy too. You want to have a rationalized plan before just jumping in, especially in the midface and the orbis to engage ophthalmology early to assess the globe and assess for a retromotor hematoma or anything that needs to be considered early on. So just to review kind of our approach to skeletal trauma recon, we use what's called kind of the facial five. We kind of break up the things in a very simple way to teach our residents and trainees about how do you, when you have a face that's been blown apart, how do you think about putting it back together and what does normal look like? And realizing what bones and what elements kind of contribute to those facial proportions helps. So number one, facial width is usually guided by the width of the face is the zygomatic arch of the widest parts of the face. Facial height is usually guided by the mandible so that you can imagine if you have a congenital neck fracture, you'll have a shortened kind of facial height, if you will. And facial projection, if you're looking at that worm's eye or basal view is guided by the cheekbones and usually the NOE midface is what we're talking about in this instance. And then obviously the fourth of the facial five is the occlusion. That's as important a unit or buttress even as some of the other skeletal buttresses that we talked about. And obviously, you're looking for just a quick scan of function, looking at the corneal nerves, basically airway, breathing, obstruction, the globe itself and parotid duct issues. So obviously adhering to AO principles, you wanna have ample yet judicious debridement of all devitalized areas and rigid fixation, but also not kind of basically lock down the jaw too much to allow for motion. You wanna know your buttresses obviously to provide landing zones for your plates. You wanna resuspend the soft tissues on the way out and really can't overemphasize this enough. I'm sure the panels will talk about this is that the use of virtual surgery planning for to create not only custom plates, but to create perfected models where you could sit back with an engineer, you're sipping your coffee, you're kind of reconstructing these pieces together. And then what you can do is go back off the table before you even get into the operating room and pre-bend your plates to fit kind of perfectly. And I'll show you an example of that that one of my colleagues performed. If you have the good fortune of a cleft and corneal facial orthodontist on campus, they can make splints for you to help with the occlusion. And obviously you can stage these procedures if it's a massive procedure, just as fatigue does sit in after we get four or five, six hours into a case like this. Always consider stable to unstable, consider staging to restore those facial fives as we listed. You wanna always break down a complex operation to more familiar elements. Bring diagrams, print out the CAT scans, and almost think about it like a rhinoplasty, write out your steps of what you're gonna address, especially in a very complicated procedure. So we'll go with our first patient, a 39-year-old female with a gunshot wound, as you can see here. Obviously the first steps are just go systematically. Critical care, look at, as you know, she has a trait. We've established feeding as well. Ophthalmology's involved to establish what's going on with the globes, the eyesight, and obviously the brain. This was, cranium was not involved in this case. I would say this is a mid-facial, a largely mid-facial issue. Just looking at her, the soft tissue, she has severe traumatic telecanthus. The nose is really split in two. She has a hard palatal injury and tongue, and aligning a cartilage deficit of the nose, clearly, with the soft tissue. Now, looking at the CAT scan, you have quite a bit of severe loss of destruction of three of the facial fives. You have loss of width, loss of projection, and the occlusion with a comminuted, what we would call, NOE, Lefort I, bilateral orbital fluors, the maxilla, alveolus, the mandible, and the hard palate. However, the good news is, is that the condyles, if you notice, are intact. So the facial height is intact, and that can give you something to build off of. And so how do you approach something like this before just diving in? Well, the first kind of set series of open reduction internal fixations, we took a debride first, wash everything out, take a bottom-up approach, restore the lower and upper facial width. My colleague who performed this, actually, used virtual surgery planning to provide a perfected model that helped them kind of reduce the facial width to get that right, and kind of reduce that NOE. And you can use those to pre-bend the plates, sterilize the plates, and bring them to the OR. They also, as you notice here, did transnasal wiring to reduce that, basically, what turned out to be a type two Markowitz fracture. And then, as you can see, there's not a lot of soft tissue loss here, externally speaking. The next steps in a situation like this is, obviously, the custom orbital floor plates. We're gonna address the rest of the mid-face and palate with an osteo-cutaneous fibula going down the pipe. Case number two, now, if you're not in the acute stage, we talked briefly about how you approach that in a systematic way, and even those acute treatments can be staged by several weeks to allow for some kind of soft tissue healing, but not too long to get more contraction. So what if you see them in a delayed fashion? So this is a 42-year-old patient of mine presented with a gunshot wound, outsider institution, but presented in my clinic about four months after the initial injury. And these are his pictures. Obviously, he comes with a trach. The soft tissue issues, including an oral dystopia. Can't see it as well on this picture, but the left eye globe was down compared to the right, which was causing double vision. He had nasal airway obstruction, complete collapse of the nasal valves, external and internal. Loss of facial projection. The occlusion and lower facial width also was a bit narrow as well and contracted. And he had a hard palatal fistula, which you can see up here. So looking at his CAT scan from when I first met him, the skeletal issues is a malposition of the NOE segment, which was never really reduced, but obviously you can see a large segment here, a little bit more comminuted here. In terms of the classifications, just like the Fort 1, 2, and 3 in the Markowitz, at least I've found in my experience that they never come exactly in pairs. They can be a LaFort 1 on this side, but a LaFort 3 on the other side. Markowitz 1 on this side, Markowitz 3 on the other side. And this is a good example of that. Obviously, the orbital rims and floors were completely destroyed, causing bilateral blowout fractures. He has loss of the medial buttress and the anterior maxilla. And obviously the mandible was never reduced and fixated and had a three-piece mandible that presented in a delayed fashion, just with some fibrous union here. The initial operations that were done, and obviously we're leaving mandible to Dr. Sinu's talk, was a custom mandible plate to reduce all this, just to kind of set everything as facial height was intact, luckily, and a left custom orbital floor. The next steps were to address the larger mid-face issues with virtual surgery planning for the fibula. And so you can see here, here was a position of our existing orbital floor plate once we put that in there, and that's based on the contralateral floor, which was not as bad, but a little bit depressed, obviously, you can see the rim out of place as well. And then our reduction using a recon plate and then another mini plate for that commutated segment for extra fixation rigidity. We then did a maxillary repositioning on both sides, and that's another advantage of the virtual surgery planning. You can span your fibula in such a way as to plan your next step for dental implants. That's precisely what we did in this gentleman, that if you're working with your implant specialist or OMFS, they can help you plan the trajectory, precise trajectory of these implants. And you want that kind of fibula aimed down a little bit because these implants, you can see at most, you want about one centimeter in the native bone stock itself, in this case, the fibula, and then you have to have enough extension and kind of cantilever down for the basically the crown of the tooth once they rehab it to get some occlusal, to create some functional occlusion. So this was the CAT scan immediately after his free fibula and we had done already our leftover floor plate. Things are in decent position here with facial width and projection have been restored. And in terms of the initial result, as you can see there. So the second stage was then the nasal reconstruction, a second orbital floor plate to balance the other side. These segments were so small. This is another thing that you can do to create a perfected model, but it ossified into a place that wasn't creating that much of an aesthetic defect. So we decided to leave them alone at the end of the day. But this is, you can see with your VSP or coronal views of how it matches our implant from the other side. We then embarked on a total nasal reconstruction now that we had set the foundation with the fibula. This was his initial presentation four months after the injury. When you're following, these pictures on the bottom basically show the restoration of mid-face projection height. This was after the free fibula and the total nasal reconstruction with restoration of lining support and bone grafts with definitely an improved result, not a perfect result by any means, but improved to be sure. The last phase, and I wanna discuss a very challenging patient that presented even in a more delayed fashion about 11 months after his initial gunshot wound. Obviously, looking at his soft tissue issues, the arhinia, near the arhinia is probably the most obvious thing. Permanent hardware, traumatic telecanthus, he's breathing out of a single lumen in the nose. So there's some lining that does go back there, but he does have a trach as you can see. Clearly his loss of facial projection and there is malposition too. And he has a microstomia as well from this initial injury and was PAKE and trach dependent. So looking at his scan, obviously he just has complete loss of bone in the mandible, obviously a loss of dentition, mid-facial structures, the NOE fracture with extensive loss of bone around the nasal bones, the face of the maxilla, and the loss of those midfacial occlusal buttresses along with loss of mandibular width. But again, facial height, luckily, and the cranium were intact. Stage 1 was a modest midface repositioning just to give myself some more time to think about the case and just move slowly with him, where we can reposition this, put a custom plate on. Stage 2 was the larger surgery, the midface repositioning, and the non-vascularized piece of the fibula that we used, because we thought we could get them in a reasonable occlusion and to restore facial width by putting a little interpositional piece of the fibula here. A and B were the vascularized portions to restore the upper midface and buttresses instead of foundation for the nose. Part C was non-vascularized about a 3.5 centimeter segment since we were otherwise going to discard it anyway and use this for the lower part of the mandibular repositioning with a custom recon plate. This was him after this initial procedure. Ultimately, about two years after the injury, we did the free fibula with the bone grafting plating. He's had a three-stage forehead flat, perimedian forehead flat. Obviously, the active issues now that he might have benefited from two fibulas or mandibular width was a little bit narrow, I feel like, and he did not want to undergo a second free flap just due to morbidity of that. However, ideally, yes, we probably could have added some tissue to help with the microstoma here and give better lower facial width with vascularized bone and a longer segment of bone. Certainly, there could have been some improved positioning of this zygomatic arch as well. He has a residual right nostril stenosis, particularly on the right, even though we did use some lining from the inside, he is contracting down. Obviously, we have not addressed formally the traumatic telecanthus. We wanted to address the nose first, why that was sequenced. It could have really been either way. But now that his priority was really building the nose, and now we're addressing the telecanthus in the next stages. The next stages also will include, as you can see here, augmenting the lower facial height with custom implant, the telecanthus, and also, even though he has a skin paddle in here to think about just some ideas about how to restore some of the oral sphincter with muscle itself. In an ideal world, had the lower lip been completely intact with no loss of tissue, one could use an AbA flap and flip this up and remove the skin paddle to just get some better sphincter tone around the orbicularis around the upper lip. Nasal stenosis, very difficult problem to treat. This is that second case that I showed you, where sometimes you can just do skin grafts over a feeding tube as we did in this gentleman, and along with serodilations, really taking a page out of folks that do their vaginoplasties with serodilation in a skin graft, in a tube, will be familiar with this. Obviously, you could use a mesolabial flap if that tissue is available to you and turn that in, so you can create a lining. Obviously, a la Frederick Minnick, using a radial forearm pre-flap, really to create the lining that you need internally. All of those fails, of course, using a permanent implant of some sort, that as a forearm body may be an option as well. But obviously, in this gentleman, from the worm's eye view, the telecanthus doesn't look that bad now that he has some dorsal projection here in the nose. But obviously, a long ways to go in terms of creating the nose and addressing the telecanthus as well. Speaking of which, this is one of those tricky things to treat that we always think the best approach to treating a NOE is at the first go-round. Once you get them, once all the scar is in there, it becomes more challenging. Just as a refresher, a normal intercanthal distance is about 30 millimeters. Depending on if you have a coronal approach, if you're going in there and fixing a frontal sinus or anything, as Dr. Kumar might have alluded to, you can certainly fix that from above. However, there's other ways to do it through an existing laceration or an extended glabellular approach as shown from the AO website nicely here. However, you do it to transdental wire or wire, really the questions I ask myself and teach the residents, is there a clear avulsion of that tendon from the bone? If there's not, you can use that transdental wiring basically to help reduce the bone. But of course, if the tendon is off, that will help you wire it back. There's multiple ways to do that. If you have loss of bone, like in the last portion I showed you, you may have to affix a mini plate, very thin mini plate, or a screw on the contralateral side to bring the tendon, either if you're using a dental wire or an ethabond, to the contralateral portion. You can use an awl, a wire passing drill guide, or a Mitek angle to achieve all those fixations. However you do it, I think it's worth bearing in mind the dimensions that on these secondary cases with very little landmarks, you're gonna have to somehow mark where that medial canthus should be. So assuming that the facial width has been restored and the lateral canthi, or the outer canthus, are where they should be, recall that your medial intercanthal distance should be approximately the width of the alar base and about one half the interpupillary distance, and about one third the outer canthal distance. So those are the important landmarks and measurements to make when you're doing that. And that's something when you go back on these secondary cases that you would go measure and tattoo. And obviously when you're fixating that canthal tendon, however you kind of grab it and fixate it to the contralateral or ipsilateral frontal bone, probably in many cases in a secondary case, if you don't have a lot of nasal bone, the fixation vector is slightly posterior and superior from the untraumatized anatomy. It's kind of overcorrect that, if you will. Obviously you want to engage ophthalmology at the same time as that operation for any delayed management of the lacrimal sac and any DCR that you might want to do. So in summation for the midface and orbital points as we wrap up that 20 minutes or so, you want to make a plan, consider staging a panface. Of course, making sure you have a stable airway and feeding. Keep in mind those facial fives and have a strategic and systematic approach for reconstruction, but also evaluating the outcomes, both for the initial and secondary and delayed operations whenever the patient is encountered in your clinical practice. Re-establish those bony buttresses first. Have a low threshold to use virtual surgery planning and orthodontist to help guide the reductions and the fixation. That can save a lot of time in the operating room. And your best shot at telekinesis correction is in those initial operations. And one thing I always told my residents and myself, you're always a student, never a master. Always very humbling to take care of these patients and help them through their next stages of life. And with that, I thank you and going on to our next panelists. Hello, it's great to be part of this panel on ballistic cranial maxillofacial injuries. I'm a craniofacial surgeon at Rainbow Babies. I'm gonna give a general overview about the algorithmic approach to facial ballistic injury. And then I believe the other panelists are gonna talk about anatomic specific areas of management of ballistic injuries. I do have a couple of disclosures. I get an educational grant from KLS Martin and I'm a consultant for J&J. So in terms of general concepts, these types of injuries represent a formidable challenge. They require surgical expertise that encompasses an amalgamation of both cranial maxillofacial skeletal surgery and soft tissue surgery, microsurgery skillsets. And the natural history of these injuries is this, this flattened, widened facial appearance with loss of the relief of the bony skeleton. I think while early patriarchs of craniofacial surgery had no interest in these injuries, in fact, the traditional World War I and World War II paradigm was early debridement, wound excision, drainage, serial dressings, and allow for closure by a secondary healing of a stabilized bone, followed by definitive secondary reconstruction. That really results in this stigmatizing, flattened, widened appearance due to the soft tissue contracture from secondary healing. Aspects of epidemiology, demographics, and outcomes of ballistic injuries have been well-documented. I think a few interesting points are that a lot of these patients go on to suffer a long-term disability, and we'll talk later about why long-term follow-up is obviously therefore important. The second thing is really these types of injuries represent a significant burden to the healthcare system in terms of the intensity and the extensive nature of the care that these patients need, as well as the financial implications. And both of those are getting worse, and our group is presenting a paper elsewhere in this meeting, really demonstrating the impact of gun violence in America is increased healthcare costs, an increase in complexity, severity, and more demand on the healthcare system. For self-inflicted injuries, the majority of these are lethal, though that does depend to some degree on how the gunshot is created and the vector of that. But of those that survive, a key point to be aware of is that reattempted suicide rate is negligible. And so really it behooves us as healthcare providers to do everything we can to reconstruct these patients in a timely fashion. Ballistic injuries are uniquely characterized by a combination of blunt, penetrating, and burn injury, and they may be further complicated by blast vasospasm as well. So that the essential difference between most blunt facial injuries and ballistic or evulsive facial injuries is the fact that there's missing or severely damaged tissue. Of course, not all facial gunshot wounds are the same. The guns themselves are classified in different ways. For example, according to the barrel length, the type of ammunition, the type of propellant, and that can have an impact on the type of injury and the severity of injury. And really the key thing is the velocity or energy of that injury. Knowing that low velocity injuries can essentially be treated as blunt facial fractures with an overlying laceration, but the real morbidity occurs in the wounds that created by the higher energy weapons. In terms of classification, trying to classify these types of injury may seem really difficult as the injury pattern can seem like it's random, but there are patterns to these injuries. And you see characteristic patterns here of low velocity gunshot wounds. There's the frontal cranium, the orbit, the lower mid face, and the mandible. And then for the higher velocity and shotgun wounds, you have the central facial injury, the lateral mandible, the lateral mid face and orbit, and the lateral cranium and orbit. I think there's probably a fifth pattern, which is sort of the contralateral orbit or nose exiting through the TMJ. And recognizing these patterns in an individual case can obviously help determine a treatment paradigm that's gonna be a restorative to that whole region affected. So low velocity injuries, like I said, can really be considered and managed as if they are blunt facial traumas, obviously complex facial traumas with comminution and bone loss with an overlying soft tissue laceration. And the management of these, therefore, depends on the anatomic region. So I don't wanna belabor this because I know the other speakers are gonna touch upon this more, but for mandible fractures, computer-aided design and computer-aided manufacturing have really allowed us to use the plate to guide reduction to avoid the need for plate bending, often avoid the need for an extra oral incision and lower profile and less palpable plates. And then for the orbit, I think these gunshot wounds often hit the four reasons why I would prefer a specific implant in a patient. Often there's more than just one wall involved. More likely to have loss of anatomic landmarks that's at the front, at the rim, and posteriorly, the posterior shelf, that you're less likely to get in a blunt injury. Often these can be revision cases as well. And then often they combine the external orbit as well as an internal orbital fracture. So all of those are indications in my mind for use of a patient-specific implant. As for the rest of the midface, if it's really highly comminuted, you may wanna avoid opening that acutely, and it may be better just to allow for that whole comminuted segment to achieve a malunion and then move it on block later. And then secondarily, some fat grafting and cartilage onlay can be useful adjuncts to camouflage any minor step-offs. So let's move on to high-velocity injuries. In high-velocity injuries, applying the standard reconstructive tenets of open reduction of bone with early replacement of soft tissue into its primary position fails. The reason it fails is because the bone's devascularized and there's inadequate soft tissue coverage often, and that leads to sepsis and nonunion. When you take that together with the fact that these patients are in critically unstable condition, often on presentation, this really warrants a staged approach for these patients that goes through diagnosis, stabilization, and then onto reconstruction. And this can really be achieved in four distinct phases that we're gonna talk about, the emergent phase, the acute phase, the subacute phase, and the delayed phase. And this is really the algorithmic approach that can take these seemingly overwhelming injuries and allow you to manage them in a controlled way. So firstly, the emergent phase. A lot of these patients are gonna have airway issues, a lot of them are gonna have bleeding issues, and a lot of them are gonna have concomitant injuries. So an evaluation and resuscitation per ATLS guidelines is absolutely mandatory. The airway particularly can be a challenge because of direct injury to the airway, because of instability of facial fractures, swelling and bleeding in the mouth. All of those can create an issue. Once the airway's been established, often falls upon us as the craniofacial team to control the facial bleeding. That can be tricky because there's collateral of the external carotid system, so that ligation is often ineffective. There can be trauma coagulopathy that makes that worse. So direct pressure and packing is gonna be the mainstay of early treatment. Often you have to pack the nose anterior and posterior to get control of that. That can be rhino rockets, putting in a Foley for posterior control or an epistat system. There are indications for angiographic embolization, so if you have an expanding hematoma, active arterial bleeding, fluctuating or progressive neurological symptoms, or a CTA evidence of a major arterial bleed, all those should lead you to consider angiographic embolization. The other thing in this phase is to really make sure there's been a thorough trauma survey to make sure there's no other injuries that have been missed. Next is the acute phase. That's gonna include a definitive and thorough facial exam to make sure there's no facial nerve deficits you need to be repairing. If there's damage to the Stenson's duct or other vital structures, patient should also have a thorough eye exam as well. This is the time to get imaging, to commence some antibiotic treatment. And then in the most part, these patients are gonna be going to the OR. And it's important for the craniofacial team to be part of that first visit to the OR. The patient's often getting that all-American procedure, the trach and PEG, but it's reasonable at that time to perform an initial conservative debridement of any definitively non-viable tissue. But then also that's a good time to tag the facial nerve branches if they're damaged, to repair the structures like Stenson's duct as I mentioned. And then a real key thing, it's gonna set your final reconstruction is to start reestablishing relationships now. And let's talk about what I mean by reestablishing relationships. So you should consider all these steps, this notion of trans-nothing wiring. If there's no nasal bone there that you can do any trans-nasal wiring, you want to set at the position of that medial canthus by just suturing or wiring one canthus to the other. You can do some early fracture stabilization. It doesn't even matter if these plates are exposed because we're going to be doing washouts and things in the subacute phase. In my mind, there's really not a need for an external fixation system in most of these patients, although that's reasonable. I would only prefer to do that if there's really gross contamination, otherwise you can just use standard plates that you're going to come back and you're going to take out down the road anyway. This skin to mucosa closure is key. Rather than, there's missing tissue, so don't always try and close skin. You can do what's called a skin to mucosa closure, and that's reestablishing the skin in the position where it should be, even though there's a defect. Often the nose and the lining of the nose is completely obliterated, but it's reasonable to put in the nasal trumpets and secure them because that's going to allow you to really still have an anatomically positioned nose. Establishing maximum mandibular fixation is key. And then if there's any lacerations in the floor of the mouth, now is a good time to get those closed and separate the floor of the mouth from the neck. The subacute phase is then really defined by serial washouts and debridement, and that's being done every 24 to 36 hours. Any exposed plates are being irrigated, foreign material and obviously devitalized tissue is removed at the initial debridement, but that's purposefully conservative. You're going to bring these patients back serially until there's no further debridement required. Then, at that point, you can then proceed to definitive bone fixation and soft tissue closure. Ideally, that should be within about a week. Anything that's excessively comminuted is going to need to be replaced, stabilizing the existing bone in its correct anatomic position with really bone grafting for the upper face and midface and bone grafting and more likely free tissue transfer for any significant defects of the lower face. At this point, you also want to restore the deficits of lining and soft tissue and bulk with any free tissue transfer. And this is the time to replace any temporary hardware that's been exposed and probably now has some biofilm with your definitive hardware. Then after that, patients are in this delayed phase of reconstruction, and that can include a plethora of different things, whether it's serial excision of any mismatched cutaneous tissue, scar revisions, dental rehab, ocular prosthesis, if indicated, there can often be some secondary eyelid procedures needed if the soft tissue injury includes that. And then obviously, for some patients, there's going to be a role for face transplantation. So in summary, looking at that algorithmic approach to the high-velocity facial ballistic injury patients, that emergent phase, controlling the airway, bleeding, and completing the trauma survey. The acute phase, really about reestablishing those relationships that are going to make your definitive reconstruction more controlled. The subacute phase allows for that to essentially heal and the extent of the injury to demarcate. Then you can have your definitive fixation and closure, followed by any secondary revisions. At our institution, we follow these patients and other facial trauma patients as part of our Life After Facial Injury program, in which we don't really see facial trauma as an acute disease, which is often seen with an undesirable patient population, undesirable lifestyle, maybe undesirable financial implications for the surgical team. Really, I think that's a gross oversimplification and does an injustice to the patients, because I believe facial trauma is really a chronic disease, albeit of acute onset. That's particularly true of these gunshot wound or ballistic injury patients. They can often have psychosocial issues, functional appearance-related issues that can be lifelong. Managing them as part of a comprehensive, interdisciplinary patient home model that follows these patients longitudinally, with an annual follow-up, with exposure to the full spectrum of supportive surgical and medical services. This program also advocates regionally and nationally for the rights of these patients and aims to improve research and outcomes, too. What we have found is that the key members of this team, as well as the craniofacial surgeon, neurosurgeons, oculoplastic surgery, general ophthalmology, psychiatry, and social work, having a concussion expert is extremely valuable, so is dentistry. Then actually having peer-to-peer support from other patients is super helpful, too. I want to acknowledge all the members of our team and thank you for your kind attention today. Hi. My name is Sinu Susarla, and I'll be talking today about managing the occlusion and complex facial injuries. I have no disclosures related to this talk, and all of the patients shown have consented to the use of their images for this presentation. The occlusion is the way the teeth come together. You can divide the occlusion in the anterior dentition, or canine to canine. The intermediate segments will be canines and premolars, or the posterior dentition, which is the molar occlusion. Malocclusion, or a lack of fit between the teeth, can be objective, something that is a definite change from the patient's pre-injury status, or subjective, where the teeth look like they fit together, but the patient thinks that maybe they don't. When you're evaluating the occlusion, you want to ask questions such as, what was the occlusion prior to the injury? Do the teeth touch everywhere? Were the dental midlines coincident, and were there any open bites or cross bites? When you're thinking about occlusal injuries, they generally follow patterns seen here. Various levels of Lefort fractures, which will alter the occlusion based on movement of the midface, and mandibular fractures. Now, these fractures can occur in isolation, but with higher energy injuries, you see things like this, where there's comminuted injuries of the midface and the mandible, and a very complex occlusal injury. Regardless, when you're evaluating and managing the occlusion in these complex types of injuries, the considerations are the same as for more straightforward injuries. You want to focus on the airway, whether there are missing or compromised teeth, missing or compromised bone, where the occlusal contacts are, and setting the centric relation. And again, regardless of the complexity of the injuries, the same principles apply. When you're thinking about the airway for these types of patients, there's lots of different options, ranging from highly impractical, which would be a straightforward oral intubation, which will make it very difficult to manage the occlusion, to highly practical, which would be submental intubation or tracheostomy. And in many patients with ballistic injuries, who might have significant intracranial injuries or polytrauma that affects respiratory function, tracheostomy is not infrequently encountered. When you're thinking about the occlusion, you want to think about it almost the same way that you think about the skeletal buttresses, and you want to restore the occlusion in the same way that you would restore a disrupted buttress of the facial skeleton. You want to think about whether there are teeth missing, and if there are teeth that are significantly injured, such as those who are evulsed or non-restorable. My criteria for removing teeth are those that are grossly displaced from the bones or mobile in at least two dimensions, fractured and otherwise non-restorable, if they're interfering with reduction or interfering with occlusion. Then you want to think about the alveolar housing itself and whether it's comminuted, and if so, is there adequate soft tissue support and vascularity to the segments such that you can reduce them and hope that they'll survive. When you're thinking about the occlusion in the context of high-energy injuries, you want to think about how disrupted it is. Both of these patients have what would contemporarily be described as panfacial injuries, but they have very different degrees of occlusal injury. The patient on the left has largely intact alveolus and dentition, the patient on the right has comminuted injuries with significant dental injuries. When you're thinking about sequencing, managing the occlusion becomes really important. In a patient with reliable dentition who has minimal comminution of the alveolus and an intact palate with a non-comminuted mandible and intact condyles, you might consider a bottom-up approach. In a patient who has the opposite set of circumstances, unreliable dentition, comminution of the alveolar housing, a split palate, comminuted mandible, fractured condyles, you might consider a top-down approach. In either event, the sequencing ends at the 4-1 level. So when you're re-establishing the occlusion in a non-comminuted situation, you're looking for consistent interdigitation, coincident or near-coincident dental midlines, no new open bites, and you need to remind yourself that the proprioceptive sensibility of the teeth is very high. So even minor occlusal discrepancies that you might not be able to detect intraoperatively may feel off to the patient. In patients with comminuted injuries, you want to prioritize removing any evolved or non-restorable teeth and debriding devitalized bone or soft tissue. And then these complex malocclusions, you want to simplify the occlusion by using things like segmental arch priors, bonnet splints, occlusal splints, intermaxary fixation appliances, and some of those are shown here. But you want to use all the tricks that you have in your bag to try to get the occlusion back into the right position. In most centers now, high-fidelity multi-detector CT scanning has become the standard for evaluation of patients with complex facial trauma. With the advent of 3D printing that many centers have in-house, you can now print the models from the CT scan with a high degree of accuracy and potentially fabricate intraocclusal splints or positioning guides based on the CAT scan alone. This has the potential to minimize the difficulties with making intraocclusal splints for repositioning. Once you have the alveolar arches reconstituted, you need to put the patient into intermaxary fixation, and there are a number of ways to do this. The method of pursuing fixation will be largely based on what your postoperative needs are. In patients who might need elastic guidance postoperatively, you're more likely to put on arch bars of some variety. In patients who need temporary fixation, you might consider things like IV loops or IMF screws. Once the occlusion is set, you want to establish the centric relation. This is the relationship of the mandible to the skull base. It is typically defined with the condyle seated within the glenoid fossa, such that they articulate along the posterior superior aspect of the articular eminence. It's independent of tooth contact, meaning it's defined by the condyle-glenoid-fossa relationship. Many normal patients may have a discrepancy between the occlusion in this position and the maximum intercuspation of the teeth. When you're intraoperatively trying to identify the cause for malocclusion, in my experience, the most common cause for an intraop malocclusion is an undiagnosed preop malocclusion. Centric relation-centric occlusion discrepancies can also be contributing to this. A technical error is when the condyles are not correctly seated when maxillomandibular fixation is applied. When you do this and you release the IMF, the condyles will reduce and you'll end up with an open bite. Specifically, what you'll see is the IMF is released and the mandible will shift toward the side that was dislocated when the MMF is released. If both condyles are out, the mandible will just fall backwards and you'll end up with an anterior open bite. A common cause for condylar dislocation during fixation is posterior bony midface interferences. This is the first area to check if this happens to you intraoperatively. When you're evaluating a patient post-op, you want to have a sense of what the on-table occlusion was. If it's right in the operating room, it'll be right post-op eventually. Generally, you should see dendrimal lines that are coincident or near-coincident and no anterior open bites. Intraarticular TMJ swelling in the first few days may make it difficult for patients to maintain the planned occlusion and guiding elastics can help with this. It's really important to note that guiding elastics cannot save a malocclusion that's related to improper reduction. If you're not confident leaving the OR that the occlusion is correct, elastics won't fix the problem. What do you do if a patient comes to you far out from trauma and has a malocclusion? This is a patient who has a malocclusion one year status post-ORF of a mandibular gunshot wound that affected the ramus condyle unit. They have an anterior open bite with sporadic contact only on the posterior teeth. This looks like it'd be a significant problem, but they were sent to the orthodontist and with clear aligner therapy, they were able to get very satisfactory occlusion. Orthodontic surgery isn't always the treatment for post-operative malocclusions. In patients with dental arch integrity that's high and good oral hygiene and access to orthodontic care, most mild to moderate malocclusions can be addressed orthodontically. Patients who have missing teeth often need dental alveolar reconstruction. When you're thinking about this, you're tasked with addressing whether bone is missing, soft tissue is missing, or both are missing. There's various options for reconstructing these types of defects ranging from complete or partial dentures, fixed prosthetics that are either tooth-borne as shown on the bottom left, or implant-borne prosthetics as shown on the bottom right. Removable prosthetics are often cumbersome for patients, particularly in the mandible. Tooth-supported prosthetics or bridges, they require intact surrounding teeth and might not be options for some patients. Implant-supported prosthetics generally require significant bone and soft tissue, but you need at least 10 millimeters of bone height and at least 5.5 millimeters of bone width at the alveolar crest. You also need keratinized tissue around the implant-oral cavity interface. This is shown here in this patient who had a defect involving the mandibular body angle and ramus condyle unit that was reconstructed with a two-segment prefibular flap. They subsequently underwent osseointegrated dental implant placement for restoration of the missing posterior teeth on that side. One of the advantages of computer-assisted surgical planning for ballistic injuries with significant bone loss is the ability to do simultaneous free tissue transfer and dental implant placement. This has been most frequently reported in the oncologic literature, but also has applications for trauma. So, this patient had a large anterior mandibular defect, which was reconstructed with a three-segment prefibular flap, and a customized guide was used to place the dental implants at the time of the microvascular reconstruction. You can see the implant placement on the top and the definitive prosthetic restoration on the bottom. Some patients with post-op malocclusions will require orthognathic surgery. This is very similar to revision or redo orthognathic surgery insofar as it often requires hardware removal, segmental, or atypical osteotomies. You may encounter attenuated buttresses that require bone grafting. This typically results in longer operating times and increased blood loss. In patients who are missing teeth and plan for prosthetic reconstruction, orthognathic surgery not only needs to be coordinated with the orthodontist, but also the restoring prosthetic dentist, so that the jaws are put into an acceptable position, not only for the occlusion, but to facilitate definitive prosthetic reconstruction. So, the take-home point is occlusion is important, but don't panic if it's not perfect in complex facial injuries. You should know the difference between an objective malocclusion and a subjective malocclusion. I tell every trauma patient with an occlusal injury that their bite will never feel exactly the same as before the injury. The priority is accurate reconstruction of the bony buttresses. Most minor to moderate occlusal discrepancies can be addressed with orthodontic treatment. Skeletal discrepancies may require osteotomies for correction, and missing teeth may need to be addressed with a coordinated surgical and dental restorative approach. Thank you.

ballistic cranio-maxillofacial injuries

facial trauma management

PSTM 23 conference

neuroinjuries

digital planning

custom plates

Life After Facial Injury

multidisciplinary teams

occlusion recovery

prosthetic solutions