Injury, Int. J.

Care Injured 40 (2009) 12521259

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Maxillofacial traumaDevelopments, innovations and controversies

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

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 17 December 2008

Despite seat belt and alcohol legislation, craniofacial trauma still remains a common health problem and
signicant workload in many maxillofacial units. Although management has evolved considerably from
wiring teeth together, complex fractures can still result in cosmetic and functional deformity. Todays
challenge is to consistently restore patients back to their pre-injury form and functionbut this is not
always possible. Greater understanding and developments have signicantly improved outcomes,
although controversy still exists in some areas. This review outlines some of these topics.
2008 Elsevier Ltd. All rights reserved.

Keywords:
Maxillofacial
Trauma
ATLS
Developments
Controversies

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Applied biomechanics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mechanisms of injury and pathophysiology . . . . . . . . . . . . . . . . . . .
Soft tissues and fracture management . . . . . . . . . . . . . . . . . . . . . . .
ATLS and facial traumacan one size fit all? . . . . . . . . . . . . . . . . .
Timing of surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Imaging in facial trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surgical approaches to the facial skeleton . . . . . . . . . . . . . . . . . . . .
Repairing facial fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Endoscopic repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Controversial topicsmanagement of the fractured Condyle56,60 . . . .
Controversial topicsmanagement of frontal sinus fractures25,58,65,136
Biomaterial developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Secondary correction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflicts of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Introduction
Despite seat belt and alcohol legislation,59,78 craniofacial
trauma122 still remains a common health problem and signicant
workload in many maxillofacial units.141 Although management
has evolved considerably from wiring teeth together, complex
fractures can still result in cosmetic and functional deformity.

* Tel.: +44 2890 484 511.

E-mail address: mikepmaxfax@yahoo.com.
00201383/$ see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2008.12.015

...
...
...
...
...
...
...
...
...
...
...
and
...
...
...
...
...

.........
.........
.........
.........
.........
.........
.........
.........
.........
.........
.........
CSF leaks24
.........
.........
.........
.........
.........

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

1252
1253
1253
1253
1253
1254
1254
1254
1255
1255
1255
1255
1256
1256
1256
1256
1256

Todays challenge is to consistently restore patients back to their

pre-injury form and functionbut this is not always possible.
Greater understanding and developments have signicantly
improved outcomes, although controversy still exists in some
areas. This review outlines some of these topics, namely;
Applied biomechanics, mechanisms of injuries and pathophysiology applicable to the face.
Soft tissues.
Advanced Trauma Life Support (ATLS) and the face.
Imaging.

M. Perry / Injury, Int. J. Care Injured 40 (2009) 12521259

Surgical approaches and repair.

Endoscopic repair.
Controversial areasTiming, plate removal, condyle and frontal
sinus.
Biomaterials and secondary correction.

1253

pupil may precipitate ocular problems. Acute angle closure

glaucoma can be precipitated by drugs13,73 and general
anaesthesiathis should be considered in any tense, painful,
red eye.
Soft tissues and fracture management

This is not an exhaustive list, but focuses on current topics and

key papers, which have shaped the management of the facial
trauma over the last 1020 years.
Applied biomechanics
Why do we have sinuses? One controversial theory104 is that
the facial skeleton has evolved into a crumple zone, preventing
impact 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 vertical
and transverse buttresses, between which the sinuses lay, covered
by paper thin bone. The thicker vertical buttresses resist functional
forces (biting), while the horizontal buttresses house the organs
(e.g. eyes) and dene facial shape, but are relatively weak and
collapse on impact. Anatomical reduction of these buttresses is
essential for the reestablishment of occlusion, facial height, width
and projection. The nasal septum is important for midface growth.

The excellent blood supply to the face has facilitated the

development of procedures not possible elsewhere in the body.
Degloved, contaminated and infected fractures often heal
uneventfully following xation,71 a situation rarely seen in the
limbs after comparable soft tissue injuries. Free-grafting 48 is
possiblebone can be detached totally from its soft tissues,
manipulated and replaced,83,88 with little risk of infection or
resorption. This has enabled development of extracorporal repair
and access orbitotomies.33 Bone can harvested from a choice of
donor sites70 (commonly calvarium, iliac crest, or rib). Conversely
care is required in comminuted fractures where severe soft tissue
damage impairs healing. Soft tissue contraction can occur and
aftercare is especially important. Careful resuspension of soft
tissues following degloving incisions is crucial for good aesthetics.
In some areas, over reduction is desirable as a degree of contraction
is inevitable.
ATLS and facial traumacan one size t all?

Mechanisms of injury and pathophysiology

Understanding mechanisms of injury can provide clues to
occult injuries,23,45 which can be initially overlooked.31,32,36,131
With regards to facial injuries;
1. Specic injuries may occur following facial impacts (cf the bellclanger effect in the mediastinum). Hippocrates noted the
association between forehead trauma and blindness74 around
400BC.39 Cervical spine injuries have also been describedwith
upper midface injuries, cervical fractures tend to be at a lower
level, while mandibular fractures are related more to upper
fractures.94
2. Fractures from altercations are simpler to reduce and treat, with
limited or no exposure and simple xation. Conversely, highenergy injuries often require extensive procedures with open
reduction and rigid xation.
3. Panfacial fractures are associated with bleeding, swelling and
airway compromise. These complications can also occur in the
absence of any fractures, in patients taking anticoagulants or
with clotting abnormalities.52 Retropharyngeal haematoma
(high cervical injuries), can result in delayed obstruction.92
Swelling worsens when supine, from elevated venous pressures
and reduced lymphatic drainage.
4. Although laminated windscreens and airbags have reduced
mortality, injuries to the periorbital region,35 globes,53 soft
tissues, temporomandibular (TMJ) joints64 and fracture of the
posterior arches of C1 and C2 are reported associations.28
5. Bone is plastic. Localised impacts can temporarily deform the
facial skeleton. Optic nerve injury can occur following forehead
and midface trauma, in the absence of fractures. Orbital apex
disruption18 can injure the tethered nerves and vessels and
resulting in blindness. Similarly blows to the cheek can result in
isolated orbital oor blowout fractures.
6. Loss of sight usually occurs immediately, but can be delayed.68 It
can also occur following apparently minor injuries, with
minimal signs of injury.14,46
7. Severe hypotension has resulted in loss of sight (ischaemic
neuropathy43,118,135)in
the
absence
of
craniofacial
trauma.12,17,41 Conversely hypertension during resuscitation
may precipitate intraocular bleeding. In the elderly a dilated

ATLS6,38,138 is generally accepted as a gold standard in

trauma.30 Unfortunately the coexistence of facial injuries and
injuries below the clavicles can pose a number of clinical
problems110,111 as each may affect the management of the
other.4,37 Even potential injuries (notably spinal), can affect
maxillofacial intervention. Conversely, facial injuries may hinder
the assessment of other body regions.11 Therefore maxillofacial
surgeons should ideally be an integral part of the trauma team
when facial injuries are evident. Facial injuries can be broadly
placed into four groups, based on clinical urgency.
1. Immediate life or sight-preserving interventions required.
2. Treatment required within a few hoursheavily 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 assessment113Direct inspection is essential. Compromise may arise from loose teeth, dentures, oropharyngeal
bleeding,132 tissue displacement, and swelling. Maintenance
techniques may be difcult with mandibular fractures. Unexpected vomiting can occur. Senior clinical input is usually
necessary.7,51
2. Rigid collars restrict mouth opening and with mandibular
fractures can precipitate airway problems.90 They can also raise
the ICP47,76 (clinical signicance unknown).
3. Life-threatening blood loss can occasionally occur. Bleeding may
continue unrecognised over a prolonged period (e.g. scalp
lacerations or in supine, awake patients who swallow their
blood). Anecdotally, even minor fractures (nasal and mandibular) have resulted in signicant blood loss requiring uid
resuscitation. Midface bleeding can be difcult to control due to
the extensive collateral supply.93
4. Damage control principles126,130 may be useful as immediate
denitive repair is not essential.112 This avoids prolonged
anaesthesia and surgery in a sick patient and facilitates
resuscitation. Sequencing is important77packing the nasal
cavity displaces unsupported midface fractures. Stabilisation

1254

M. Perry / Injury, Int. J. Care Injured 40 (2009) 12521259

techniques include bite blocks, wires, splints, intermaxillary

xation (IMF), or plating. External xation provides rapid rst
aid stabilisation where there is tissue loss or contamination.
5. Bilateral external carotid ligation is traditionally described for
persistent bleeding.140 However, this is time consuming, has
limited success (ethmoid collaterals) and may be required in
uncleared necks. Supra-selective embolisation29,89,98 is
increasingly being reported as an effective alternative.107
Multiple bleeding points can be identied34 and the technique
is repeatable. Immediate access to facilities and on site expertise
are essential.
6. Initial assessment of the eyes3,114 and visual pathways must
condently exclude sight threatening injuries.9 Detailed examination can be performed later. Any sight-preserving procedures
must then be performed as quickly as possible.5,16,21,66 The main
problem is rapidly making such diagnoses,55 as this is often
based on a limited clinical examination. Clinical judgement is
often necessary (e.g. very tense proptosed globe). Flash Visual
Evoked Potentials (VEPs42,79,97) have been used to assess the
visual pathway, but the equipment is currently cumbersome
and not suited for the emergency room.
Timing of surgery
The best time to repair complex facial injuries in the multiply
injured patient remains controversial. Historically, treatment was
deferred until intracranial injuries had been managed, sometimes
by many weeks. However there has been a move towards the early
and total repair of facial injuries,22,26,63,102 often within the rst
few days50 and sometimes, hours of injury. Complex cases require
wide exposures, anatomical reduction and primary bone grafting.103,119 This is believed to result in much better functional and
aesthetic outcomes. With long delays (around 14 days) soft tissues
become adherent, making repair difcult. This is particularly
important in the canthal region of the eye, a very difcult area to
correct secondarily. However, this approach has to be balanced
against the patients overall condition. Prolonged early surgery
may add to the rst biologic hit and subsequent risk of MOF.86,130
Repair is also difcult if signicant swelling is present. By delaying
surgery, swelling can resolve and further assessment, planning and
patient consent can be undertaken. The optimal time to
denitively repair facial fractures is still not known, although
probably varies from case to case.
Imaging in facial trauma
Computed tomography (CT) has revolutionised the assessment
of complex injuries.27,101,123 With the newer high speed scanners,
CT of the face is now possible at the same time as other body
regions,61 avoiding additional transfers and delays in management. Surgeons can now co-ordinate treatments enabling craniofacial fractures to be treated comprehensively. CT is particularly
useful in assessment of the skull base, orbits, sinuses and condyles.
Because rapid identication of some vision-threatening injuries is
essential, indications for scanning should include the mechanism
of injury (cf torso injuries).106 On this basis any patient requiring a
brain CT,144 who has suspected midface injuries, should also
undergo imaging of (at least) the orbits.62,99 The following affect
early management.
1.
2.
3.
4.
5.
6.

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

Removal of foreign bodies from the orbit and neck is difcult

due to limited access, altered anatomy or the proximity of vital
structures. Image intensication and ultrasound are helpful, but
CT-guided navigation systems now enable precise orientation of
surgical instruments,133 visualised on a monitor in the operating
theatre. Repair and reconstruction of complex orbital anatomy has
particularly beneted from this. 3D imaging is also readily
available now and together with anatomical models87 enables
preoperative planning, model surgery and fabrication of custom
implants, saving operating time.
MRI is sometimes used in the assessment of soft tissue changes
in the temporomandibular joint67. Disc displacement, capsular
tears and haemarthrosis have been reported to reect the degree of
injury sustained. Ultrasound has been used in the diagnosis of
facial fractures, notably orbital injuries.81,105 It has also been used
to conrm reduction of zygomatic arch fractures, but has
limitations in the presence of surgical emphysema.
Surgical approaches to the facial skeleton
Internal xation has resulted in the need for aesthetically
placed incisions. Most mandibular and midface fractures are now
approached through the mouth, although skin incisions (or
lacerations) may be used in upper midface and some comminuted
mandibular fractures. Although larger rigid xation plates are
available for lower mandibular border xation, their use is
debatable as miniplates can be placed transorally and have low
morbidity. Screws are placed transorally or via a small stab wound
in the cheek (transbuccally)which is best is currently also a
matter of debate and surgeons preference. Common cutaneous
approaches include:
1. Condylar fracturesThe preauricular approach139 provides
access in high neck and intraarticular fractures. For lower
fractures, the retromandibular100/transparotid/submandibular
approaches may be used. Complications are generally rare, but
include injury to the facial nerve and salivary stulae.
2. Upper face (e.g. Nasoethmoid, zygoma). The traditional open
sky or seagull incisions provide good exposure to the nasal
bridge and medial orbits, but result in obvious scarring. These
have now been replaced by more aesthetic incisions. An upper
blepharoplasty incision provides surprisingly good access to the
zygomatico-frontal suture and lateral orbital wall and has
superseded the lateral eyebrow incision in many units. Skin
incisions are still possible over the bridge of the nose, but these
should be placed in skin creases to minimise visible scars. Repair
can 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 oor and lower parts of
the orbital walls (medial and lateral) and can be extended
medially20 and laterally. If deeper access to the posterior orbit is
required, orbitotomy (temporary removal of the lower orbital
rim) improves this. The rim can later be replaced and secured
with a microplate.
4. Extensive craniofacial fractures.1 Access may be possible
through single or multiple incisions, depending on a number
of factors. The coronal scalp ap145 provides complete and
uninterrupted visualisation of almost the entire upper face and
frontal region. It also allows cranial bone to be harvested,
avoiding a second donor site. Potential complications include
facial nerve injury,2 diplopia, telecanthus, alopecia and scalp
necrosis.
5. Midfacial degloving.19 This has gained popularity offering good
exposure 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) 12521259

scarring. In combination with a transconjuctival incision it has

been used as an alternative to the coronal incision. To date there
do not appear to be any signicant postoperative complications
reported.
6. Nasal injuries. Although commonly managed by closed manipulation, 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, intermaxillary
xation, dental (cap) splints and external xation. Such closed
methods were essentially blind manipulations, where the only
guides to reduction were the bite, palpation or postoperative lms.
Reduction relied on fragments locking together under an intact
periosteum. Not surprisingly these resulted in poor outcomes.
Nowadays many fractures are treated by open reduction, with
improved precision, aesthetics and functional outcomes.69 However panfacial fractures are still extremely challenging. Adequate
access and correct sequencing are essential to restore facial height,
width, projection and the occlusion. Particular attention is
required in the posteromedial orbit and inner canthal region
both are key to good aesthetics. IMF is still used in some mandible
fractures, although this is mostly in minimally displaced and
condylar fractures. Its principle is simple: if the teeth are secured in
occlusion the fractures will be adequately reduced and stabilized.
Elastics are now commonly used, rather than wires. However IMF
is difcult to use in pre-existing malocclusions, missing, loose or
damaged teeth. Attached muscles may still displace the bony
fragments. Vomiting can also be difcult to manage.
Plates are available in different sizes, depending on the amount
of support required across a particular fracture site. Both load
bearing and load sharing xation systems have been developed.
Load bearing is possible where there is substantial bone present to
support loading across bicortical screws, notably in the mandible.
Both screws and plates are, by necessity, large and need to be
removed, although patients can fully function very soon after
fracture repair. Miniplates are small and can be left in situ. In the
mandible the tension band principle is used.40,75 Consequently
they can be secured with small monocortical screws, which can be
safely placed over dental roots and the inferior alveolar nerve.
Fine tuning of the occlusion is possible using elastics and arch
bars. Self-drilling screw are now available. Microplates and
screws are used to repair small or thin fragments (frontal sinus,
orbital rim and nasal bones). This has led to novel uses in laryngeal
fractures.80
Routine removal of these devices is debatable. Stress shielding
is minimal and concern centres on how inert titanium really
is.85,121 Release of titanium into local tissue and particle migration
to the lungs is well documented.137,142 Allergy and potential
carcinogenic effects have also been raised. Nevertheless the
general consensus is that titanium is much more stable than
other alternatives currently available.
Endoscopic repair
Endoscopy is widely used in craniofacial surgery and increasingly so in trauma.49,91 Compared to conventional techniques it
results in less tissue damage, complications and shorter recovery.
Common indications include:
1.
2.
3.
4.
5.

CSF leaks (controversial).

TMJ arthroscopy (diagnostic and therapeutic).
Condylar fractures.96,127,128
Isolated anterior frontal sinus fractures.143
Selected midface, orbital oor and zygomatic arch fractures.

1255

6. Endoscopic control of epistaxis is well described,57 but of limited

use in pan facial fractures where multiple bleeding points are
present. Currently these techniques are best used in localised
nasal injuries.
Controversial topicsmanagement of the fractured Condyle56,60
Condylar fractures are common and account for up to half of
all mandibular fractures. Controversy still exists over management in adults (patients over the age of 12). In children
nonsurgical functional treatment results in good outcomes
as condyles can regenerate and remodel.72 Even fracture dislocations can be successfully managed this way. However in
adults incorrectly treated fractures can lead to signicant
functional impairmentdysocclusion, restricted and deviated
mouth opening.
The role of open reduction is controversial. Functional IMF still
produces acceptable results,8 bony union and complications are
rare. However many surgeons now believe that modern techniques
and surgical experience carry minimal risks and produce better
long 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 restore
the bite with closed reduction, displacement of the condyle into
the middle cranial fossa (a rare complication) or laterally, and an
overlying open wound with foreign body. In bilateral cases it has
been 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 topicsmanagement of frontal sinus fractures25,58,65,136
and CSF leaks24
This complex anatomical area should always be considered
along with nasoethmoid fractures, as bone fragments may
damage the frontonasal duct (FND). Fractures often follow
high-energy impacts and therefore may be associated with
intracranial, cervical and ocular injuries. However patients can
also present in relatively good neurological condition, in keeping
with the crumple zone theory. The management of frontal sinus
fractures is controversial and undertaken by several surgical
specialities. Complications are potentially very serious and
mostly occur with displaced posterior wall fractures. Most
complications occur within the rst 6 months but there is a
life-long risk of othersmucocele, mucopyocele, and brain
abscess have all been reported 50 years following injury.108
Other complications include osteomyelitis, meningitis,44 CSF
leakage, headaches, and cosmetic deformity.
CT has greatly facilitated assessment and treatment planning.
Original treatments involved exenteration of the sinus allowing
the overlying skin to collapse onto the dura thereby preventing
mucus collection and secondary infection. This was later modied
by preserving the supraorbital rims in order to improve cosmetic
appearances. Today, the aim of surgery are to create a safe sinus
(isolate and protect intracranial structures, stop cerebrospinal uid
leakage, prevent complications), and restore facial aesthetics. How
this is best done falls into three main campssinus obliteration,
cranialisation and reestablishment of anatomy and drainage. Many
protocols and procedures exist, but as yet there is no unied,
evidence-based approach to these complex injuries. Long term
follow up and hence long term critical evaluation of these various
strategies is very difcult. Access often involves a bicoronal
approach enabling craniotomy and the use of pericranial aps.
Post-operatively valsalva maneuvers such as nose blowing, closed-

1256

M. Perry / Injury, Int. J. Care Injured 40 (2009) 12521259

mouth sneezing, or strenuous activities must be avoided. General

principles include:
1. Nondisplaced fractures of the anterior table with no FND
obstruction should be treated nonoperatively.
2. Displaced isolated anterior wall fractures can be repaired or
secondarily reconstructed.
3. Management of complex injuries depends on the presence of
frontonasal duct injury and dural tears.
4. Sinus mucosa must be meticulously removed and the bone
scaried with burrs to remove residual mucosa.
5. Sinus obliteration120the sinus is obturated with a number of
materials.84 Autologous bone, fat, pericranium and muscle are
safe but can resorb. Synthetic materials (acrylic resin, Gelfoam,
and bone pastes) have also been used but are at risk of
absorption, infection and extrusion.
6. Cranialisation of the sinusthe posterior wall of the sinus is
removed, dura repaired and the intracranial contents isolated
from the nose by obturating the FND. This approach is more
commonly undertaken in the presence of persistent cerebrospinal uid leakage.
CSF leaks are uncommon and usually resolve without surgical
intervention. Conrmation requires testing for the presence of b2
transferrin, as glucose levels and the target sign, or ring test are
not reliable. Antibiotics are not recommended, due to acquired
resistance. Initially leaks are observed for 710 days, followed by
CSF diversion (lumber drain) for 57 days. If repair is required
high-resolution CT or intrathecal uorescein are needed to identify
the site of leakage. Repair can be performed either intracranially,
extracranially or endoscopically and falls outwith the remit of this
review.
Biomaterial developments
Although titanium is not the ideal material it has been used for
over a decade, due to adequate biocompatibility and mechanical
properties. Contact with the dura does not seem to produce clinical
problems. However particle migration, local reactions, thermal
paraesthesia, and interference with CT scans have led to the search
for more biocompatible materials and in some units there is now a
trend towards the use of bioresorbable materials. Research is also
ongoing into the development of a bone glue. Various polymers
have been developed which degrade by hydrolysis into water and
carbon dioxide. Resorbable xation is now well established in
children, particularly in the skull, where passive migration of metal
plates occurs during growth. However biodegradable screws have
less mechanical stability and swelling of the plates occurs during
degradation. Tapping is sometimes necessary. Ultrasound-aided
pin xation115 is a relatively new means of osteosynthesis. Instead
of screws, a pin is inserted into the drill hole using an ultrasound
stimulated melting (welding) process. The pin liquees and ows
into the trabecular bone as well as welding to the plate. Pins can be
inserted at different angles, torque forces are avoided, and there is
no need for tapping.
Materials commonly used95,117 (more for secondary reconstruction than primary repair) include:
1.
2.
3.
4.
5.

Silicone.
P.T.F.E. (polytetraurorethylene).
Hydroxyapatite and other bone source.
Medpore (porous polyethylene54).
Titanium129.

Bone morphogenetic proteins116,124 (BMPs) have also received

a lot of interest in the restoration of bony defects, although they are
currently 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. Despite
these advances and developments the harsh reality is that in a
signicant number of patients we still fall short of this standard.
This is more likely following high-energy trauma (comminuted
fractures and severe soft tissue injury), where treatment is delayed,
or complications develop. Secondary correction may then be
required. This has also benetted from many of the same
developments.
Crudely speaking tissues can be considered as missing (avulsion
injuries), excessive (hypertrophic scars, residual callus) or
displaced (nonanatomical repair). This simple approach helps
plan treatment. Detailed clinical assessment involves determining
both functional and aesthetic problems. This can be supplemented
with imaging usually CT. In addition to lms, dimensionally
accurate 3D models can now be fabricated109,125 Stereolithography134 and laser sintering are processes where model are made
from liquid light-cured monomer or plastic powder. Osteotomies
can then be performed, plates pre-bent and implant size and
shapes determined. By inverting images and using subtraction
techniques the difference between injured and non-injured side
can be calculated and custom implants fabricated without the need
for models. Computer-assisted guidance facilitates exact placement of these preformed implants through smaller incisions with a
reported accuracy of 1 mm. This is particularly useful in orbital and
cranial reconstruction. Unfortunately there are still limitations.
Metal and motion artefacts, partial volume effect and shrinkage of
the resin can contribute to inaccuracies. Reconstruction of
combined bone and soft tissue deformity is difcult due to
unpredictable soft tissue changes. New algorithms for soft tissue
reconstruction may solve these problems in the future.
Reconstruction of soft tissue defects is generally more difcult
than bone as soft tissue contraction increases the risks of relapse in
posttraumatic correction. A number of techniques are available
(e.g. injection of bone substitutes, onlays, or implantation of fat and
free tissue transfer). These are extremely technique dependent.
Summary
The management of the injured face has undergone major
changes following greater understanding of the healing process
and with advances in technology. Outcomes are considerably
better than 30 years ago as more comprehensive assessment and
management is now possible. Nevertheless the goal of consistently
restoring patients back to their pre-injury form and function still
eludes maxillofacial surgeons as in both our patients, and
ourselves, expectations have subsequently increased.
Conicts of interest
None.
References
1. Abubaker AD, Sotereanos G, Patterson GT. Use of the coronal surgical incision
for reconstruction of severe craniofacial injuries. J Oral Maxillofac Surg
1990;48:57982.
2. Al-Kayat A, Bramley P. A modied pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 1979;17:913.
3. Al-Qurainy IA, Stassen LF, Dutton GN, Moos KF, el Attar A. The characteristics of
midfacial fractures and the association with ocular injury: a prospective study.
Br J Oral Maxillofac Surg 1991;29:291301.
4. Alvi A, Doherty T, Lewen G. Facial fractures and concomitant injuries in trauma
patients. Laryngoscope 2003;113:1026.
5. Amagasaki K, Tsuji R, Nagaseki Y. Visual recovery following immediate
decompression of traumatic retrobulbar haemorrhage via transcranial
approach. Neurol Med Chir (Tokyo) 1998;38:2214.

M. Perry / Injury, Int. J. Care Injured 40 (2009) 12521259

6. American College of Surgeons Committee on Trauma. Advanced trauma life
support for doctors ATLS, 7th ed., Chicago, IL: American College of Surgeons;
2004.
7. American Society of Anesthesiologists. Practice guidelines for the management of the difcult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difcult Airway. Anesthesiology
1993;78:597602.
8. Andersson J, Hallmer F, Eriksson L. Unilateral mandibular condylar fractures: a
31-year follow-up of non-surgical treatment. Int J Oral Maxillofac Surg
2007;36:3104.
9. Ansari MH. Blindness after facial fractures: a 19-year retrospective study. J
Oral Maxillofac Surg 2005;63:22937.
10. Appling WD, Patrinely JR, Salzer TA. Transconjunctival approach vs. subciliary
skin-muscle ap approach for orbital fracture repair. Arch Otolaryngol Head
Neck Surg 1993;119:10007.
11. Ardekian L, Rosen D, Klein Y, Peled M, Michaelson M, Laufer D. Life threatening
complications and irreversible damage following maxillofacial trauma. Injury
1998;29:2536.
12. Asensio JA, Forno W, Castillo G, Roldan, Gambaro E, Petrone P. Posterior
ischemic optic neuropathy related to profound shock after penetrating thoracoabdominal trauma. South Med J 2002;95:10537.
13. Ates H, Kayikcioglu O, Andac K. Bilateral angle closure glaucoma following
general anesthesia. Int Ophthalmol 1999;23:12930.
14. Babajews A, Williams JL. Blindness after trauma insufcient to cause bony
injury: case report and review. Br J Oral Maxillofac Surg 1986;24:711.
15. Bahr W, Bagambisa FB, Schlegel G, Schilli W. Comparison of transcutaneous
incisions used for exposure of infraorbital rim and orbital oor: a retrospective
study. Plast Reconstr Surg 1992;90:58591.
16. Bailey WK, Kuo PC, Evans LS. Diagnosis and treatment of retrobulbar haemorrhage. J Oral Maxillofac Surg 1993;51:7802.
17. Basile C, Addabbo G, Montanaro A. Anterior ischemic optic neuropathy and
dialysis: role of hypotension and anaemia. J Nephrol 2001;14:4203.
18. Bater MC, Ramchandani PL, Ramchandani M, Flood TR. An orbital apex fracture
resulting in multiple cranial neuropathies. Br J Oral Maxillofac Surg
2008;46:1634.
19. Baumann A, Ewers R. Midfacial degloving: an alternative approach for traumatic corrections in the midface. Int J Oral Maxillofac Surg 2001;30:2727.
20. Baumann A, Ewers R. Transcaruncular approach for reconstruction of medial
orbital wall fracture. Int J Oral Maxillofac Surg 2000;29:2647.
21. Beadles KA, Lessner AM. Management of traumatic eyelid injuries. Semin
Ophthalmol 1994;9:14551.
22. Becelli R. Craniofacial traumas: immediate and delayed treatment. J Craniofac
Surg 2000;11(July):2659.
23. Belanger HG, Scott SG, Scholten J, Curtiss G, Vanderploeg RD. Utility of
mechanism-of-injury-based assessment and treatment: Blast Injury Program
case illustration. J Rehabil Res Dev 2005;42:40312.
24. Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal uid leak
associated with craniomaxillofacial trauma. J Oral Maxillofac Surg
2004;62:67684.
25. Bell BR, Dierks EJ, Brar P, Potter JK, Potter BE. A protocol for the management of
frontal sinus fractures emphasizing sinus preservation. J Oral Maxillofac Surg
2007;65:82539.
26. Benzil DL, Robotti E, Dagi TF, Sullivan P, Bevivino JR, Knuckey NW. Early singlestage repair of complex craniofacial trauma. Neurosurgery 1993;30:16671.
discussion 171172.
27. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol
2002;12:123752.
28. Blacksin MF. Patterns of fracture after air bag deployment. J Trauma
1993;35:840.
29. Borsa JJ, Fontaine AB, Eskridge JM, Song JK, Hoffer EK, Aoki AA. Transcatheter
arterial embolization for intractable epistaxis secondary to gunshot wounds. J
Vasc Interv Radiol 1999;10:297302.
30. Bose D, Tejwani NC. Evolving trends in the care of polytrauma patients. Injury
2006;37:208.
31. Brooks A, Holroyd B, Riley B. Missed injury in major trauma patients. Injury
2004;35(April):40710.
32. Brooks AJ, Sperry D, Riley B, Girling KJ. Improving performance in the management of severely injured patients in critical care. Injury 2005;36(February):3106.
33. Burkat CN, Lemke BN. Retrobulbar hemorrhage: inferolateral anterior orbitotomy for emergent management. Arch Ophthalmol 2005;123:12602.
34. Bynoe RP, Kerwin AJ, Parker Jr HH, et al. Maxillofacial injuries and lifethreatening hemorrhage: treatment with transcatheter arterial embolization.
J Trauma 2003;55:749.
35. Cacciatori M, Bell RW, Habib NE. Blow-out fracture of the orbit associated with
ination of an airbag: a case report. Br J Oral Maxillofac Surg 1997;35:241.
36. Campell AS, Butler AP, Grandas OH. A case of external carotid artery pseudoaneurysm from hyoid bone fracture. Am Surg 2003;69:5345.
37. Cannell H, Dyer PV, Paterson A. Maxillofacial injuries in the multiply injured.
Eur J Emerg Med 1996;3(March):437.
38. Carmont MR. The Advanced Trauma Life Support course: a history of its
development and review of related literature. Postgrad Med J 2005;81:8791.
39. Chadwick J. The medical works of hippocrates. Springeld, IL: Thomas; 1950.
40. Champy M, Lodde JP, Schmitt R, Jaeger JH, Muster D. Mandibular osteosynthesis by miniature screwed plates via a buccal approach. J Maxillofac Surg
1978;6:1421.

1257

41. Chang SH, Miller NR. The incidence of vision loss due to perioperative ischemic
optic neuropathy associated with spine surgery: the Johns Hopkins Hospital
Experience. Spine 2005;30(June 1):1299302.
42. Cornelius CP, Altenmuller E, Ehrenfeld M. The use of ash visual evoked
potentials in the early diagnosis of suspected optic nerve lesions due to
craniofacial trauma. J Craniomaxillofac Surg 1996;24(1):111.
43. Cullinane DC, Reddy S, Bass JG. Anterior ischaemic neuropathy. J Trauma
1999;47(July):210.
44. Cultrera F, Giuffrida M, Mancuso P. Delayed post-traumatic frontal sinus
mucopyocoele presenting with meningitis. J Cranio-Maxillofac Surg
2006;34:5024.
45. Dalati T. Isolated hyoid bone fracture Review of an unusual entity. Int J Oral
Maxillofac Surg 2005;34:44952.
46. Dancey A, Perry M. Blindness after blunt facial trauma: are there any clinical
clues to early recognition? J Trauma 2005;58(February):32835.
47. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial
pressure. Injury 1996;27(November):6479.
48. Davis BR, Powell JE, Morrison AD. Free-grafting of mandibular condyle fractures: clinical outcomes in 10 consecutive patients. Int J Oral Maxillofac Surg
2005;34:8716.
49. Deng M, Dong H, Long X, Li X, Cheng Y. Endoscope-assisted reduction of
longstanding condylar dislocation. Int J Oral Maxillofac Surg 2007;36:7525.
50. Derdyn C, Persing JA, Broaddus WC, Delashaw JB, Jane J, Levine PA, Torner J.
Craniofacial trauma: an assessment of risk related to timing of surgery. Plast
Reconstr Surg 1990;86(August):23845. discussion 246247.
51. Diaz JH. The difcult intubation kit. Anesthesiol Rev 1990;17(5, September
October):4956.
52. Diecidue R, Richard J, Spera J, Streck P. Post-traumatic haemorrhage in a
patient with previously undiagnosed von Willebrands disease. J Oral Maxillofac Surg 2000;58:3326.
53. Driver PJ, Cashwell LF, Yeatts RP. Airbag-associated bilateral hyphemas and
angle recession (letter). Am J Ophthalmol 1994;118:250.
54. Duman H, Deveci M, Uygur F, Sengezer M. Reconstruction of contour and
anterior wall defects of frontal bone with a porous polyethylene implant. J
Cranio-Maxillofac Surg 1999;27:298301.
55. Dutton GN, Al-Qurainy IA, Stassen LFA, et al. Ophthalmic consequences of
midface trauma. Eye 1992;6:86.
56. Eckelt U, Schneider M, Erasmus F, et al. Open versus closed treatment of
fractures of the mandibular condylar process a prospective randomized multi
centre study. J Craniomaxillofac Surg 2006;34:306.
57. El-Guindy A. Endoscopic transantral sphenopalatine artery ligation for intractable posterior epistaxis. Ann Otol Rhinol Laryngol 1998;107:10337.
58. El Khatib K, Danino A, Malka G. The frontal sinus: a culprit or a victim? A
review of 40 cases. J Cranio-Maxillofac Surg 2004;32:314.
59. El-Maaytah M, Smith S, Jerjes W, et al. The effect of the new 24 hour alcohol
licensing law on the incidence of facial trauma in London. Br J Oral Maxillofac
Surg 2008;46(6, September):4603.
60. Ellis E, Simon P, Throckmorton GS. Occlusal results after open or closed
treatment of fractures of the mandibular condylar process. J Oral Maxillofac
Surg 2000;58:2608.
61. Exadaktylos AK, Sclabas G, Schmid S, Zimmermann H. Do we really need
routine CT scanning in the primary evaluation of blunt chest trauma in
patients with normal chest radiograph? J Trauma 2001;51:11736.
62. Exadaktylos AK, Sclabas GM, Smolka K, et al. The value of computed tomographic scanning in the diagnosis and management of orbital fractures associated with head trauma: a prospective, consecutive study at a level I trauma
center. J Trauma 2005;58(February):33641.
63. Gabrielli M, Aparecida M, Gabrielli C, Hochuli-Vieira E, Pereira-Fillho V.
Immediate reconstruction of frontal sinus fractures: review of 26 cases. J Oral
Maxillofac Surg 2004;62:5826.
64. Garcia R. Air bag implicated in temporomandibular joint injury. J Craniomandib Pract 1994;12:125.
65. Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus
fractures: current surgical management and complications. J Cranio-Maxillofac Surg 2000;28:1339.
66. Gerbino G, Ramieri A, Nasi A. Diagnosis and management of retrobulbar
haematomas following blunt orbital trauma: a description of eight cases.
Int J Oral Maxillofac Surg 2005;34:12731.
67. Gerhard S, Ennemoser T, Rudisch A, Emshoff R. Condylar injury: magnetic
resonance imaging ndings of temporomandibular joint soft-tissue changes.
Int J Oral Maxillofac Surg 2007;36:2148.
68. Ghufoor K, Sandhu G, Sutcliffe J. Delayed onset of retrobulbar haemorrhage
following severe head injury: a case report and review. Injury 1998;29:139
41.
69. Gruss JS, Phillips JH. Complex facial trauma: the evolving role of rigid xation
and immediate bone graft reconstruction. Clin Plast Surg 1989;93:104.
70. Gruss JS. The role of primary bone grafting in complex craniomaxillofacial
trauma. Plast Reconstr Surg 1985;75(January):1724.
71. Gruss JS, Antonyshyn O, Phillips JH. Early denitive bone and soft-tissue
reconstruction of major gunshot wounds of the face. Plast Reconstr Surg
1991;87(January):43650.
72. Gue O, Keskin A. Remodelling following condylar fractures in children. J
Cranio-Maxillofac Surg 2001;29:2327.
73. Hall SK. Acute angle-closure glaucoma as a complication of combined betaagonist and ipratropium bromide therapy in the emergency department. Ann
Emerg Med 1994;23:8847.

1258

M. Perry / Injury, Int. J. Care Injured 40 (2009) 12521259

74. Harrison DW, Wails RN. Blindness following minor head trauma in children: a
report of two cases with a review of the literature. J Emerg Med 1990;8:214.
75. Haug RH, Barber JE, Reifeis R. A comparison of mandibular angle fracture
plating techniques. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1996;82:25763.
76. Ho AM, Fung KY, Joynt GM, Karmakar MK, Peng Z. Rigid cervical collar and
intracranial pressure of patients with severe head injury. J Trauma 2002;53(6):
1851188.
77. Holmes S, Coghlan K, McAllinden P, Hardee P, Chan O. Complications with use
of the Epistat in the arrest of midfacial haemorrhage. Injury 2003;34:9017.
78. Hutchison I, Magennis P, Shepherd J, Brown A. The BAOMS United Kingdom
Survey of Facial Injuries. Part 1. Aetiology and the association with alcohol
consumption. Br J Oral Maxillofac Surg 1998;36:313.
79. Ikejiri M, Adachi-Usami E, Mizota A, et al. Potentials in traumatic optic
neuropathy. Ophthalmologica 2002;216:4159.
80. Islam S, Shorafa M, Hoffman G, Patel P. Internal xation of comminuted
cartilaginous fracture of the larynx with mini-plates. Br J Oral Maxillofac Surg
2007;45:3212.
81. Jank S, Emshoff R, Etzelsdorfer M, Strobl H, Nicasi A, Norer B. The diagnostic
value of ultrasonography in the detection of orbital oor fractures with a
curved array transducer. Int J Oral Maxillofac Surg 2004;33:138.
82. Jensen J, Sindet-Pedersen S, Christensen L. Rigid xation in reconstruction of
craniofacial fractures. J Oral Maxillofac Surg 1992;50:5504.
83. Joachim EZ, Mischkowski RA, Behr R, Ernestus R-I, Speder B. The fronto-orbital
osteotomy as plastic-reconstructive approach to the anterior and middle skull
base. J Cranio-Maxillofac Surg 2001;29:15964.
84. Kalavrezos ND, Gruitz K, Warnke T, Sailer HE. Frontal sinus fractures: computed tomography evaluation of sinus obliteration with lyophilized cartilage. J
Cranio-Maxillofac Surg 1999;27:204.
85. Katou F, Andoh N, Motegi K, Nagura H. Immuno-inammatory responses in
the tissue adjacent to titanium miniplates used in the treatment of mandibular
fractures. J Craniomaxillofac Surg 1996;24:15562.
86. Keel M, Trentz O. Pathophysiology of polytrauma. Injury 2005;36:691709.
87. Kermer C, Lindner A, Friede I, Wagner A, Millesi W. Preoperative stereolithographic model planning for primary reconstruction in craniomaxillofacial
trauma surgery. J Cranio-Maxillofac Surg 1998;26:1369.
88. Kiyokawa K, Hayakawa K, Tanabe H, et al. Cranioplasty with split lateral skull
plate segments for reconstruction of skull defects. J Cranio-Maxillofac Surg
1998;26:37985.
89. Komiyama M, Nishikawa M, Kan M, Shigemoto T, Kaji A. Endovascular treatment of intractable oronasal bleeding associated with severe craniofacial
injury. J Trauma 1998;44:3304.
90. Kreisler NS, Durieux ME, Spiekermann BF. Airway obstruction due to a rigid
collar. J Neurosurg Anaesthesiol 2000;12:1189.
91. Krimmel M, Cornelius C-P, Reinert S. Endoscopically assisted zygomatic
fracture reduction and osteosynthesis revisited. Int J Oral Maxillofac Surg
2002;31:4858.
92. Kuhn JE, Graziano GP. Airway compromise as a result of retropharyngeal
hematoma following cervical spine injury. J Spinal Disord 1991;4(3, September):2649.
93. Last RJ. Anatomy regional and applied, 6th ed., Churchill Livingstone; 1978.
94. Lewis VL, Manson PN, Cerullo LJ, Meyer PR. Facial injuries associated with
cervical fractures: recognition, patterns and management. J Trauma
1985;25:903.
95. Maas CS, Merwin GE, Wilson J, Frey MD, Maves MD. Comparison of biomaterials for facial bone augmentation. Arch Otolaryngol Head Neck Surg
1990;116:5516.
96. Loukota RA. Endoscopically assisted reduction and xation of condylar neck/
base fractures the learning curve. Br J Oral Maxillofac Surg 2006;44:480.
97. Mahapatra AK, Bhatia R. Predictive value of visual evoked potentials in
unilateral optic nerve injury. Surg Neurol 1989;31(May):33942.
98. Mahmood S, Lowe T. Management of epistaxis in the oral and maxillofacial
surgery setting: an update on current practice. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2003;95:239.
99. Manfredi J, Raji MR, Sprinkle PM, Weinstein GW, Minardi LM, Swanson TJ.
Computerised tomographic scan ndings in facial fractures associated with
blindness. S Plast Reconstr Surg 1981;68:479.
100. Manisali M, Amin M, Aghabeigi B, Newman L. Retromandibular approach to
the mandibular condyle: a clinical and cadaveric study. Int J Oral Maxillofac
Surg 2003;32:253.
101. Manson PN, Markowitz B, Mirvis S, Dunham M, Yaremehuk M. Toward CTbased facial fracture treatment. Plast Reconstr Surg 1990;85:20212.
102. Manson PN, Crawley WA, Yaremchuk GM, Rockamnn J, Hoopes E, French JH.
Midface fractures: advantages of immediate extended open reduction and
bone plating. Plast Reconstr Surg 1985;76:110.
103. Marciani RD, Gony AA. Principles of management of complex craniofacial
trauma. J Oral Maxillofac Surg 1993;51(May):53542.
104. Martin Jr RC, Spain DA, Richardson JD. Do facial fractures protect the brain
or are they a marker for severe head injury? Am Surg 2002;68(May):477
81.
105. McCann PJ, Brocklebank LM, Ayoub AF. Assessment of zygomatico-orbital
complex fractures using ultrasonography. Br J Oral Maxillofac Surg
2000;38:5259.
106. Melton SM, Kerby JD, McGifn D, et al. The evolution of chest computed
tomography for the denitive diagnosis of blunt aortic injury: a single-center
experience. J Trauma 2004;56:24350.

107. Moreau S, DeRugy MG, Babin E, Courtheoux P, Valdazo A. Supraselective

embolisation in intractable epistaxis: review of 45 cases. Laryngoscope
1998;108:8878.
108. Mourouzis C, Evans B, Shenouda E. Late presentation of a frontal mucoele-50
years post injury. J Oral Maxillofac Surg 2008;66(7):15103.
109. Ono I, Gunji H, Suda K, Kaneko E. Method for preparing an exact-size model
using helical volume scan computed tomography. Plast Reconstr Surg
1994;93(7):136371.
110. Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size
t all? Part 1. Dilemmas in the management of the multiply injured patient
with coexisting facial injuries. Int J Oral Maxillofac Surg 2008;37:20914.
111. Perry M, Dancey A, Mireskandari K, Oakley P, Davies S, Cameron M. Emergency
care in facial traumaa maxillofacial and ophthalmic perspective. Injury
2005;36(August):87596.
112. Perry M, OHare J, Porter G. Advanced Trauma Life Support (ATLS) and facial
trauma: can one size t all? Part 3. Hypovolaemia and facial injuries in the
multiply injured patient. Int J Oral Maxillofac Surg 2008;37:40514.
113. Perry M, Morris C. Advanced Trauma Life Support (ATLS) and facial trauma:
can one size t all? Part 2. ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg 2008;37:30920.
114. Perry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma:
can one size t all? Part 4. Can the patient see? Timely diagnosis, dilemmas
and pitfalls in the multiply injured, poorly responsive/unresponsive patient.
Int J Oral Maxillofac Surg 2008;37:50514.
115. Pilling E, Mai R, Theissig F, Stadlinger B, Loukota R, Eckelt U. An experimental
in vivo analysis of the resorption to ultrasound activated pins (Sonic weld1)
and standard biodegradable screws (ResorbX1) in sheep. Br J Oral Maxillofac
Surg 2007;45:44750.
116. Rasubala L, Yoshikawa H, Nagata K, Iijima T, Ohishi M. Platelet-derived growth
factor and bone morphogenetic protein in the healing of mandibular fractures
in rats. Br J Oral Maxillofac Surg 2003;41:1738.
117. Reddi SP, Stevens MR, Kline SN, Villanueva P. Hydroxyapatite cement in
craniofacial trauma surgery: indications and early experience. J Cranio-Maxillofacial Trauma 1999;5:712.
118. Remigio D, Wertenbaker C. Postoperative bilateral vision loss. Surv Ophthalmol 2000;44:42632.
119. Robotti E, Forcht D, Ravegnani M, Bocchiotti G. A new prospect on the approach to
open, complex, craniofacial trauma. J Neurosurg Sci 1992;36(AprilJune):8999.
120. Rohrich RJ, Mickel TJ. Frontal sinus obliteration: in search of the ideal autogenous material. Plast Reconstr Surg 1995;95:5805.
121. Rosenberg A, Gratz KW, Sailer HF. Should titanium miniplates be removed
after bone healing is complete? Int J Oral Maxillofac Surg 1993;22:1858.
122. Rowe NL, Williams JLI. Maxillofacial Injuries. Vol. I, II. Chicago: Quintessence,
158221; 1986, 4313.
123. Russell J, Davidson M, Daly B, Corrigan A. Computed tomography in the
diagnosis of maxillofacial trauma. Br J Oral Maxillofac Surg 1990;28:28791.
124. Sakou T. Bone morphogenetic proteins: from basic studies to clinical
approaches. Bone 1998;22:591603.
125. Santler G, Kircher H, Ruda C. Indications and limitations of three-dimensional
models in cranio-maxillofacial surgery. J Cranio-Maxillofac Surg 1998;26: 1116.
126. Schwab J. Introduction: damage control at the start of 21st century. Injury
2004;35:63941.
127. Schoen R, Fakler O, Metzger MC, Weyer N, Schmelzeisen R. Preliminary
functional results of endoscope-assisted transoral treatment of displaced
bilateral condylar mandible fractures. Int J Oral Maxillofac Surg 2008;37:
1116.
128. Schoen R, Fakler O, Gellrich NC, Schmelzeisen R. Five year experience with the
transoral endoscopic-assisted treatment of displaced condylar mandible fractures. Plast Reconstr Surg 2005;116:4450.
129. Scholza M, Wehmo M, Lehmbrockc J, et al. Reconstruction of the temporal
contour for traumatic tissue loss using a CAD/CAM-prefabricated titanium
implant-case report. J Cranio-Maxillofac Surg 2007;35:38892.
130. Shapiro MB, Jenkins DH, Schwab CW, et al. Q1 damage control: collective
review. J Trauma 2000;49:96978.
131. Sharma BR, Gupta M, Harish D, Singh VP. Missed diagnoses in trauma patients
vis-a-vis signicance of autopsy. Injury 2005;36:97683.
132. Shimoyama T, Kaneko T, Horie N. Initial management of massive oral bleeding
after midfacial fracture. J Trauma 2003;54:3326.
egger M, Mischkowski RA, Schneider BT, Krug B, Klesper B, Zoeller JE.
133. Sieu
Image guided surgical navigation for removal of foreign bodies in the head and
neck. J Cranio-Maxillofac Surg 2001;29:3215.
134. Stoker NG, Mankovich NJ, Valentino D. Stereolithographic models for surgical
planning. J Oral Maxillofac Surg 1992;50:46671.
135. Suzuki D, Ilsen PF. Hypovolemic ischemic optic neuropathy. Optometry
2000;71(August):50110.
136. Swinson BD, Jerjes W, Thompson G. Current practice in the management of
frontal sinus fractures. J Laryngol Otol 2004;118:927.
137. Torgessen S, Moe G, Jonsson R. Immunocompetent cells adjacent to stainless
steel and titanium miniplates and screws. Eur J Oral Sci 1995;103:4654.
138. Van Olden GD, Meeuwis JD, Bolhuis HW, Boxma H, Goris RJ. Clinical impact of
advanced trauma life support. Am J Emerg Med 2004;22(November):5225.
139. Vesnaver A, Gorjanc M, Eberlinc A, Dovsak D, Kansky A. The periauricular
transparotid approach for open reduction and internal xation of condylar
fractures. J Cranio-Maxillofac Surg 2005;33:16979.
140. Waldron J, Stafford N. Ligation of the external carotid artery for severe
epistaxis. J Otolaryngol 1992;21:24951.

M. Perry / Injury, Int. J. Care Injured 40 (2009) 12521259

141. Warburton AL, Shepherd JP. Alcohol-related violence and the role of oral and
maxillofacial surgeons in multiagency prevention. Int J Oral Maxillofac Surg
2002;31(November):65763.
142. Weingart D, Steinemann S, Schilli W, et al. Titanium deposition in regional
lymph nodes after insertion of titanium screw implants in maxillofacial
region. Int J Oral Maxillofac Surg 1994;23:4502.

1259

143. Yoo MH, Kim JS, Song HM, Lee BJ, Jang YJ. Endoscopic transnasal reduction of
an anterior table frontal sinus fracture: technical note. Int J Oral Maxillofac
Surg 2008;37:5735.
144. Zee CS, Go JL. CT of head trauma. Neuroimag Clin N Am 1998;8(August):52539.
145. Zhang Q, Dong Y, Li Z, Zhao J. Coronal incision for treating zygomatic complex
fractures. J Cranio-Maxillofac Surg 2006;34:1825.