Facial Reconstruction After Car Accident

The interesting case that I’d like to discuss today was this really nice gal that presented to me after being in a severe car accident and sustaining significant facial fractures and being repaired at an outside facility and hospital. Her injuries included a left zygoma, or cheekbone fracture, including a significant periorbital and orbital floor component, and a left mandible fracture. Now, this mandible fracture went horizontally along the ramus separating the proximal distal fragment, and in the proximal fragment was the coronoid process and the condylar process, so just picture the condyle and the cornonoid process and the sigmoid notch and then a fracture going horizontal along separating those two from the rest of the mandible.

The patient healed with a significant facial depression on the left with her cheekbone being displaced posteriorly and inferiorly. This greatly increased the orbital volume, leading to her eye looking small and settled back, which is called enophthalmos, and as well the pupil was significantly lower than the right and uninjured side, and we call this a vertical dystopia. The patient also had a blown pupil, meaning her pupil was dilated and will always be dilated from injury, and this is called a traumatic mydriasis.

The patient also had a significant malocclusion, and when she presented to me she was already in braces, getting her teeth aligned for a future planned bilateral sagittal split osteotomy. Upon further conversation with this patient, she was really concerned about the position and the look of her face and her eye, and note that she also had a traumatically detached retina that was just about to be repaired. She essentially had very little vision of the left eye and could sense light but really see nothing more than that.

My plan for this patient, in addition to the bilateral sagittal split osteotomy advancement, was and was executed as follows. First, I acquired a CT scan, and then I had the unaffected side duplicated and mirror imaged on the affected side, and then a PEEK implant was fabricated by Stryker to fill the void between where the body of the zygoma and the infraorbital rim should be and actually were, so this is a custom-fit facial implant that helps fill the void. Now, it was also noted that the zygomatic arch was protruding out significantly, and I decided that osteoplasty would help reduce this prominence. For the orbital issues, I decided that an orbital reconstruction with the placement of an orbital floor implant would address the enophthalmos as well as the vertical dystopia.

The patient was worked up and had the implants fabricated and was taken to the operating room. The procedure began by making a subciliary incision. This allowed me to dissect down to the infraorbital rim, which was then exposed. There was some hardware that had to be removed and was easily done so. The body of the zygoma was dissected out underneath the periosteum and a tunnel posteriorly to the prominence of the zygomatic arch was issolated, and the prominence was reduced by protecting the soft tissue with retractors and decreased the prominence of the zygomatic arch.

An incision was then made in the left maxillary vestibule, and the dissection went down and then became continuous with the superior dissection. In addition, a dissection was done posteriorly into the orbital vault, and the orbital floor was isolated and the orbital contents were elevated.

Once the entire surgical site was opened, the infraorbital implant and the zygomatic implant were then fed in through the subciliary incision and keyed in quite nicely to the planned position. It was stabilized with a total of three screws so that the PEEK implant did not drift or move over time. An orbital floor implant was then contoured and made to elevate and reconstruct the orbital floor back to its pre-injury position, and stabilized to the infraorbital rim using a couple of screws. The vertical height of the globes was then checked and appeared to be symmetric from the right to the left. A forced duction test was then done to ensure that the globe could move and that there was no entrapment. At this point, I was able to complete the mandibular bilateral sagittal split osteotomy advancement and use some fixation plates on the left and the right-hand sides to stabilize the osteotomy sites, and all of the surgical sites were copiously irrigated and then closed appropriately.

The patient was aroused from general aesthetic, extubated, and taken to recovery and did quite well post-operatively. The patient did develop a significant post-operative infection and was admitted for some IV antibiotics, and has responded quite nicely to the IV antibiotics, and now is doing quite well.

The PHOTOS from this case during the surgery are particularly awesome and definitely worth a peek!

For the full "Facial Reconstruction After Car Accident" podcast episode click here.

For more interesting cases, and to listen to more full episodes visit DentistBrainCandy.com or text "CANDY" to 77948