EPPOCRATIS: A Point-of-Care Utilization of Virtual Surgical Planning and Three-Dimensional Printing for the Management of Acute Craniomaxillofacial Trauma

While virtual surgical planning (VSP) and three-dimensional planning (3DP) have become important tools in acute craniomaxillofacial surgery, the incorporation of point of care VSP and 3DP is crucial to allow for acute facial trauma care. In this article, we review our approach to acute craniomaxillofacial trauma management, EPPOCRATIS, and discuss current challenges and future directions in acute facial trauma management.

A Demographic Analysis of Craniomaxillofacial Trauma in the Era of COVID-19

Study Design: Retrospective cohort study. Objective: The challenges of COVID-19 could magnify socioeconomic vulnerability for craniomaxillofacial (CMF) trauma. This study compares subjects who presented with CMF fractures to a regional healthcare system during the pandemic with those in 2019. We hypothesized societal circumstances of 2020 would correlate with disproportionately more CMF fractures in vulnerable patients compared to pre-pandemic trends. Methods: An IRB approved retrospective study of CMF fracture presentations in 2019 and 2020 was performed. Demographics, injury details, and management details were collected. A residence-based poverty index was calculated for each subject utilizing census data. Pre-pandemic and pandemic cases were compared to identify differences between cohorts. Results: A large decrease in presentations was noted between pre-pandemic and pandemic cohorts. There was significantly greater poverty the pre-pandemic cohort as compared to the pandemic cohort ( P = .026). Overall, there was a significant correlation between higher poverty and violent MOI ( P < .001). This association was maintained pre-pandemic, ( P = .001) but was insignificant in the pandemic cohort ( P = .108). Difference between cohorts with respect to violent injury was non-significant ( P = .559) with non-significant difference in demographics including age ( P = .390), place of injury ( P = .136), employment status ( P = .905), insurance status ( P = .580), marital status ( P = .711), ethnicity ( P = .068), and gender ( P = .656). Management was not significantly different between cohorts including percent hospital admission ( P = .396), surgical intervention ( P = .120), and time to operation ( P = .109). Conclusions: Contrary to our hypothesis, this analysis indicates that the societal changes brought on by the COVID-19 pandemic did not magnify vulnerable populations. Some changes were noted including in volume of presentation, demographic distribution, and injury detail.

Radiographic Optic Nerve Findings and Their Clinical Implications in the Setting of Craniomaxillofacial Trauma

Purpose: Computed tomography (CT) scans obtained in the setting of facial trauma often report aberrations in neural anatomy, such as optic nerve stretching. While these findings have not yet been correlated with clinical findings, they raise concern for traumatic optic neuropathy (TON). This study aims to correlate radiographic optic nerve abnormalities with clinical findings in the setting of craniomaxillofacial trauma. Methods: Patient charts were queried based on ICD-9 codes for the presence of an orbital fracture. Patients were included if the CT report mentioned an anatomic abnormality of the optic nerve. Patients who expired within 24 hours of arrival, had an open globe injury, or who were not able to participate in a visual exam were excluded. An additional matched cohort of patients with orbital fractures and without optic nerve abnormalities was selected. The primary endpoint was a clinical diagnosis of TON, and secondary endpoints included the need for ophthalmologic intervention and the presence of abnormal visual acuity. Results: One-hundred and eight patients were included in the study (54 per group). Radiographic optic nerve stretching was not associated with an increased risk of TON (OR: 2.22, 95% CI: 0.71-7.02); however, it was associated with increased risk for abnormal visual acuity (OR: 2.24, 95% CI: 1.01-4.99). There was no increased need for any ophthalmologic intervention (OR: 1.93, 95% CI: 0.86-4.31). Conclusions: Alterations in orbital anatomy on CT are common after orbital fracture and may inappropriately raise concern for TON. This in turn may prompt interfacility transfer and/or emergent ophthalmology consultation. This study demonstrates that radiographic stretching of the optic nerve does not increase the odds for TON in the setting of orbital fractures. While patients with abnormal optic nerve findings did have a higher rate of abnormal visual acuity, this is a common, multifactorial finding in this setting.

Role of Finite Element Analysis in Oral and Maxillofacial Surgery - A Review

BACKGROUND Maxillofacial surgeries vary from simple tooth extraction to maxillofacial reconstruction and rehabilitation. The intricate anatomy of the facial bones and complex vital structures surrounding them makes it challenging for the surgical teams to perform complex surgeries. With the rapid change in technology and modern advancement in virtual surgeries, there is a leap towards improvement in healthcare. To study biomechanical properties, it is imperative to include the principles of physical science in the field of medicine. In recent times, Finite element analysis (FEA) has become a useful tool to study the biomechanical properties of craniofacial structures under different mechanical parameters. Since the human structure's biomechanics is not possible to study on an experimental basis, finite element analysis has become an emerging tool to solve these complex biomechanical equations. The finite element method uses a numerical calculation of small heterogeneous geometry into the simple linear equation and predicts biomechanical responses towards each variation. Although used extensively in engineering, this method finds extensive use in the medical field, from planning surgeries to design external prosthesis. This method's most significant advantage includes studying a model outside the body, designing an idle surgical instrument and hardware, models that can be replicated based on user requirements, no ethical consideration needed, and print prosthesis that exactly resembles a typical anatomical structure. This method has certain limitations: high cost, technical flaws, and inability to replicate exact clinical conditions. This review article covers the current FEA scope in maxillofacial surgeries, steps in planning surgeries, advantages, disadvantages and the modifications needed to refine it for future research. KEYWORDS Finite Element Analysis, Craniomaxillofacial Trauma, Orthognathic Surgery, FEA

Bone reconstruction surgery of complex craniomaxillofacial deformities using additive manufacturing customized implants - a case report

Purpose This study aims to assess the design, manufacturing and surgical implantation of three-dimensional (3D) customized implants, including surgical preoperative planning, surgery and postoperative results, for cranioplasty along with zygomatic and orbital floor implants using additive manufacturing (AM) technics for a 23-year-old female who suffered from severe craniomaxillofacial trauma. Design/methodology/approach The skull biomodel was produced in polyamide while implants were made of a Ti-6Al-4V alloy by AM. Findings The method enabled perfectly fitting implants and anatomical conformance with the craniomaxillofacial defect, providing complete healing for the patient. Surgical planning using a customized 3D polyamide biomodel was effective. This proved to be a powerful tool for medical planning and manufacturing of customized implants, as complete healing and good craniofacial aesthetic results were observed. Originality/value Satisfactory surgical procedures, regarding surgery time reduction and good craniofacial aesthetic results, were achieved. Furthermore, the 3D titanium customized implants represented a favorable alternate for the repair of craniomaxillofacial defects.

Computer Assisted Guided Placement of IMF Screws in Craniomaxillofacial Trauma: An Evolving Technique

Intermaxillary fixation (IMF) screws have been introduced into maxillofacial trauma practice to reduce operation time and the complications associated with the placement of wire ligatures around teeth. Wires continue to be used to secure arch bars to teeth, form eyelets and long ligatures prior to putting a patient into maxillomandibular fixation (MMF). The application of wires to dental arches may result in sharp injuries to the operator, whereas injury to roots and nerves may arise from incorrect positioning of IMF screws in the jaws. The purpose of this technical note is to demonstrate how 3D patient specific (PS) surgical guides can be planned and fabricated to assist in the safe placement of IMF screws in the maxilla and mandible. It is proposed that PS IMF screw guides can be further developed to incorporate removable spoons and semi-circular access ports that not only facilitate safe screw placement but allow the guide to remain in position until all screw are secured. The potential benefits of PS IMF surgical guides include diminished risk of injury to facial structures and reduced operation time. The technique also lends itself to the placement of IMF screws via a robotic arm contributing to a safer operating environment for the maxillofacial surgery team.