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DR. BHUPENDRA HARJA M.D.S

Introduction
Injuries to the face, head and neck are relatively common and yet, in the overall trauma literature, very little attention has been paid to malunion fracture cases of maxillofacial region. Fractures of maxillofacial region have been treated by a number of methods, including closed reduction, external pin fixation, internal wire fixation and more recently, open reduction and internal stable fixation using plates and/or screws.
In last few years maxillofacial surgery emerged out as major field in modern era of surgical practice. But due to lack of awareness and specialist expertise availability in most of the areas of our country such injuries may go undiagnosed or most of times wrongly diagnosed and treated as well. Other reason for such delay in expertise treatment of maxillofacial injuries is its association with other life threatning injuries which may compromise the overall treatment planning of less life threatning injuries.
How to draw a base line to start treatment of such patients? As such as there is no treatment protocol available in the literature which can guide us to build a definitive line of treatment for treatment of malunion facial fractures specially for midface region. However we can follow certain basic principles for management of post traumatic skeletal deformity.

1.Accurate examination and assessment by history, clinical examination and special investigations.
2.Treatment planning
3.Surgery, utilizing a variety of techniques for management of soft and hard tissue deficits or deformities, including osteotomies and bone grafting.
4.Treat each case as a new case.


History
The most important aspect of history is documentation of the patient’s complains and concerns. A number of potentially correctable deformities may be present, but it is important to assess which of these require correction in order to address the concern of the patient. A through assessment of the psychosocial effect of the deformity may help to highlight important areas, since relatively minor physical abnormalities may give rise to significant psychological, social or occupational problems. Time elapsed between the injury, primary and secondary surgery is very important because some problems are better corrected early, while others may be less critical.

Examination
No diagnostic aids can bypass the role of thorough examination by an experienced surgeon. Assessment should be logical and must include all the areas of the craniofacial skeleton including both soft tissue and hard tissue. The presence of cutaneous scars, soft tissue deficiency and distortions or subcutaneous fat atrophy may limit the extent of bony movement and/or the degree of soft tissue response to the underlying bony movement and leave a persisting esthetic or functional deficit even if a perfect underlying skeletal position can be achieved. In addition, what may seem to be a bony asymmetry may be solely due to Soft tissue problems. Special attention should be paid while examining orbitozygomatic deformity, globe displacement in the vertical or anteriorposterior plane needs to be accurately assessed and the presence of characteristic stigmata of enophthalamos, such as pseudoptosis, implies a degree of displacement of orbital tissues.

Special investigations

Include plain flims. CT and MRI scanning. Plain films will demonstrate the site and extent of the original injuries, the presence of bone plates, wires, and grafts used in primary treatment. AP and Lateral cephalometry may be useful for detailed measurements of malpositions and asymmetries. Dental study models are mandatory for assessment of post traumatic deformity Involving tooth bearing fragments of the maxilla or the mandible. CT scanning in axial coronal planes can provide very useful information in complex midface, orbitozygomatic deformity and claviral defects. Additional benefit of CT scanning is its ability to generate three dimensional images. The recent introduction of stereolithographic models allows direct visualization of the defect.

Treatment Planning
A good homework done by the surgeon prior to operation can give marvelous results to the patient. Intraoperative judgment of the extent of necessary bone movement or augmentation to achieve symmetry is extremely difficult, due to distortion of overlying soft tissues as a result of surgical access, edema, presence of an endotracheal tube and inaccessibility of normal reference points beneath sterile drapes.
Concern of patient should always be on the top of the sugeon’s priorty. If a portion of a craniofacial skeleton is malpositioned or deficient and is giving rise to patient concerns or complaints, it should be restored to its normal anatomical position, shape or volume. However, in planning treatment , it must be borne in mind that correction of one deformity may result in accentuation of another, which may not have been previously noticed by the patient, e.g. malar osteotomy may make a previously mild enophthalamos more obivious.
Most of all it is essential to discuss with the patient the proposed correction and ensure a realistic expectation of outcome, including both the positive and negative effects of any proposed surgery.

Treatment Techniques
Surgical access to the entire craniofacial skeleton can be obtained by bicoronal flap, lower eyelid or transconjuctival and intraoral buccal sulcus incisions. For mandible intraoral buccal sulcus incision, submandibular incision, retromandibular incision and sometimes even preauricular incision. A major looking deformity can be corrected by very simple measures while a mild deformity can sometimes demand a major and relatively complex surgical procedures. Various osteotomies need to be done at various level. For maxilla osteotomy at lefort I, II and/or III level may be required. In addition to this osteotomy via previous bone fracture scar can sometimes be carried out. For mandible malunion at different sites may require different tratment approaches either we can do osteotomy through old bone scar or if malunion is behind the tooth bearing segment e.g malunited angle, ramus and condylar fractures might cause severe malocclusion and/or compromised tempromandibular joint function. Vertical subsigmoid, inverted L or sagittal split osteotomy can be done to correct unilateral occlusal cant. Malunion condylar fracture causing compromised tempromandibular joint function need to be corrected by reduction of condylar fragment and disc repositioning.

Case Presntation
A 21 years old boy presented with history of trauma due to road traffic accident. When the patient reported he has already being operated for his maxillofacial injuries around two months back. Patient now presented with chief complaint of diplopia, squint and deformed facial looks. On examination of the patient following relevant points have been noted.
1. Patient has depressed nasal bridge.
2. Medial squint of right eye.
3. Diplopia on right lateral gauze.
4. Tenderness over nasal bridge region.
5. Tenderness and crepitus over left fronto zygomatic suture region.
6. Malocclusion and molar gagging.
7. Paresthesia over left cheek region
8. Forced duction test revealed no neurological cause for diplopia.
About this patient was unaware of malocclusion as he was on IMF, from previous operation.
 

fig.1 preoperatively note the marked squint of right eye
fig.2 preoperatively note depressed nasal bridge.
fig.3 occlusion preoperatively


CT scan slice showing medial wall of right eye fracture and left zygomatic complex fracture.


Patient was taken under G.A. through tracheostomy tube (in situ from previous operation). Buccal sulcus incision was given in maxilla, all implants and wires were removed. After that osteotomy was planned, instead of going for a separate lefort I osteotomy. It was decided to refracture the maxilla through original fracture line with the help of osteotome. The maxilla was mobilized with the help of Rowe’s disimpaction forcep and manipulated to achieve occlusion. After doing IMF only single point fixation done with 1.5mm plating system at buttress region. So that some manipulation can be done with help of traction elastics if needed to achieve occlusion. Mandible arch form although slightly expanded but as satisfactory occlusion was achieved no attempt was made to perform additional surgery on mandible. Left side FZ suture opened through eye brow incision fracture segment were manipulated to achieve approximation and prominence over cheek. A 1.5mm system 5 hole plate is secured with help of 2 screws on each side of fracture line. Next nasal bones were manipulated with help of Walsham’s forceps and Ash’s septal forsep. Petroleum jelly nasal pack was given. A satisfactory nasal bridge reduction was achieved, next a butterfly shaped plaster of paris splint was given and secured with help of dynaplast. After this when forced duction test was performed on right eye decrease in resistance in movement of eye ball is noted.

Post operatively patient was placed on class III traction elastics for 48 hrs and then on IMF for 15 days. A satisfactory facial look was appreciated by the patient after the operation. Marked improvement in diplopia and medial squint of right was noted. Occlusion achieved was satisfactory. Two months after operation there was no diplopia, no medial squint at all and occlusion achieved was stable.
 

fig.3 occlusion preoperatively

Patient was taken under G.A. through tracheostomy tube (in situ from previous operation). Buccal sulcus incision was given in maxilla, all implants and wires were removed. After that osteotomy was planned, instead of going for a separate lefort I osteotomy. It was decided to refracture the maxilla through original fracture line with the help of osteotome. The maxilla was mobilized with the help of Rowe’s disimpaction forcep and manipulated to achieve occlusion. After doing IMF only single point fixation done with 1.5mm plating system at buttress region. So that some manipulation can be done with help of traction elastics if needed to achieve occlusion. Mandible arch form although slightly expanded but as satisfactory occlusion was achieved no attempt was made to perform additional surgery on mandible. Left side FZ suture opened through eye brow incision fracture segment were manipulated to achieve approximation and prominence over cheek. A 1.5mm system 5 hole plate is secured with help of 2 screws on each side of fracture line. Next nasal bones were manipulated with help of Walsham’s forceps and Ash’s septal forsep. Petroleum jelly nasal pack was given. A satisfactory nasal bridge reduction was achieved, next a butterfly shaped plaster of paris splint was given and secured with help of dynaplast. After this when forced duction test was performed on right eye decrease in resistance in movement of eye ball is noted.
Post operatively patient was placed on class III traction elastics for 48 hrs and then on IMF for 15 days. A satisfactory facial look was appreciated by the patient after the operation. Marked improvement in diplopia and medial squint of right was noted. Occlusion achieved was satisfactory. Two months after operation there was no diplopia, no medial squint at all and occlusion achieved was stable.
 

fig.4 postoperative marked improvement in diplopia and squint.
fig5 postoperatively marked improvement in profile

Discussion
Malunited fractures have always been a big challenge to the surgeon. Most important of all in approaching such cases is to have a proper history and requirement of the patient. The one which is most concerned to the patient should be on top priority. Occlusion is a point on which no compromise is acceptable.
Minimally invasive procedures and relatively simple measures can some times yield a marked improvement in net result. For.eg. a malunited zygomatic complex fracture can be osteotomised and satisfactorily stabilized by two relatively stable point of fixation, one at frontozygomatic suture and the other at buttress region. Similarly in bijaw malunion fracture cases if satisfactory occlusion is achieved by doing osteotomy of only single jaw as maxilla in above case than there is no need to go for doing osteotomy of other jaw. In this case medial squint and diplopia was due to muscle entrapment(medial rectus) of right eye which was effectively released after doing closed reduction of NOE and nasal fracture. Traction elastics as in above case has sometimes a significant role in achieving occlusion.
So a calculated approach should be taken while operating such cases. Treat each case as a new case and set criteria of your own depending upon the patient situation and its requirement. At last above all is patient satisfaction as it is supreme judge of the surgery performed.

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