Paul S. Tiwana

Long-term clinical outcome analysis of poly-methyl-methacrylate cranioplasty for large skull defects

PURPOSE The goal of secondary cranioplasty is permanent cerebral protection in an esthetically acceptable fashion. Reconstruction of cranial defects can be performed with several different materials. Alloplastic materials, such as preformed methyl-methacrylate (PMMA) cranioplasties, are an alternative frequently used at our institution. This retrospective analysis was designed to review the outcomes of PMMA cranioplasty for skull defect reconstruction. MATERIALS AND METHODS Seventy consecutive patients who had 78 PMMA cranioplasties placed from 2003 through 2010 were identified. Mechanism of injury, location of cranioplasty, type of original repair, postoperative complications, and follow-up time were reviewed. RESULTS Of the 70 patients, 6 patients had failure and removal of their original PMMA cranioplasty and reinsertion of another, and 2 patients had failure and removal of 2 cranioplasties with replacement of a third, creating a total of 78 PMMA cranioplasties placed. The predominant mechanism of injury was trauma (64%). The most frequent postoperative complication was infection (13%). With the exception of the 2 patients with implant exposure, no patients reported an unacceptable cosmetic result. An overall complication rate of 24% was seen. CONCLUSIONS The results of previous studies have shown that infection and complication rates of cranioplasties accomplished with bone cement are substantially higher, that titanium-based implants may obscure follow-up imaging for tumor patients, and that the outcomes regarding hydroxyapatite-based ceramics, although similar to PMMA, are associated with a much higher cost. PMMA remains a cost-effective and proven method to repair cranial defects that fulfills the goals of cranial reconstruction for skull defects.

Parameters of Care for Craniosynostosis

Background A multidisciplinary meeting was held from March 4 to 6, 2010, in Atlanta, Georgia, entitled “Craniosynostosis: Developing Parameters for Diagnosis, Treatment, and Management.” The goal of this meeting was to create parameters of care for individuals with craniosynostosis. Methods Fifty-two conference attendees represented a broad range of expertise, including anesthesiology, craniofacial surgery, dentistry, genetics, hand surgery, neurosurgery, nursing, ophthalmology, oral and maxillofacial surgery, orthodontics, otolaryngology, pediatrics, psychology, public health, radiology, and speech-language pathology. These attendees also represented 16 professional societies and peer-reviewed journals. The current state of knowledge related to each discipline was reviewed. Based on areas of expertise, four breakout groups were created to reach a consensus and draft specialty-specific parameters of care based on the literature or, in the absence of literature, broad clinical experience. In an iterative manner, the specialty-specific draft recommendations were presented to all conference attendees. Participants discussed the recommendations in multidisciplinary groups to facilitate exchange and consensus across disciplines. After the conference, a pediatric intensivist and social worker reviewed the recommendations. Results Consensus was reached among the 52 conference attendees and two post hoc reviewers. Longitudinal parameters of care were developed for the diagnosis, treatment, and management of craniosynostosis in each of the 18 specialty areas of care from prenatal evaluation to adulthood. Conclusions To our knowledge, this is the first multidisciplinary effort to develop parameters of care for craniosynostosis. These parameters were designed to help facilitate the development of educational programs for the patient, families, and health-care professionals; stimulate the creation of a national database and registry to promote research, especially in the area of outcome studies; improve credentialing of interdisciplinary craniofacial clinical teams; and improve the availability of health insurance coverage for all individuals with craniosynostosis.

Management of Atrophic Edentulous Mandibular Fractures: The Case for Primary Reconstruction With Immediate Bone Grafting

t s m c n trophic edentulous mandibular fractures, particuarly bilateral fractures (Fig 1) have always posed a roblem for not only those who suffer them, but lso for the treating surgeon. The patients are often lderly and infirm. The bone is brittle; often the onsistency of porcelain, the surface area is quite mall, and the entire bone-periosteal complex has arkedly diminished healing capacity. Opposing uscle groups come into play, both displacing and indering reduction of the fractures and comproising stability. The diminished surface area of the racture allows no load sharing capacity, and the one adjacent to the fracture does not lend itself to crew fixation. The construction of accurate dental plints is difficult if not impossible to achieve. All of hese factors can mitigate the successful outcome

Management of comminuted fractures of the mandible.

Comminuted fractures of the mandible are unusual but not rare. They are complex injuries with a high complication rate. Gunshot wounds are a frequent cause. Traditional management with closed techniques is noted for good long-term results, but may involve an extended period of treatment. Treatment with open reduction and rigid internal fixation significantly shortens the course of treatment and simplifies the convalescence.

Mandibular Fractures: An Analysis of the Epidemiology and Patterns of Injury in 4,143 Fractures

PURPOSE The objective of this study was to complete a comprehensive retrospective review of the epidemiology and patterns of injury in mandibular trauma based on the Parkland Memorial Hospital trauma database over a 17-year period. The authors identified 4,143 fractures in 2,828 patients from the databank. In mandibular trauma, the mechanism of injury and several other variables can be an important point of differentiation with regard to fracture pattern. By showing the statistical relation between these and fracture pattern, the authors hope to provide surgeons with a better understanding of such a relation. MATERIALS AND METHODS Mandibular fracture data were collected from the Parkland Memorial Hospital trauma registry using International Classification of Diseases, Ninth Revision codes (802.21 to 802.39). Information included fracture type, age, gender, mechanism of injury, and associated injuries. The Parkland Memorial Hospital trauma registry yielded 4,143 mandibular fractures in 2,828 patients managed at Parkland Memorial Hospital from 1993 through 2010. RESULTS Based on retrospective analysis, results were obtained for age, gender, monthly distribution, anatomic distribution, and mechanism of injury. The average age was approximately 38 years, with most patients (33%) in the third decade. An overwhelming majority of patients were men (83.27%), with only 16.27% consisting of women. Most injuries occurred in the summer months, with July being the most common month of occurrence. The mechanism of injury predominantly involved low-velocity blunt injuries (62%) compared with high-velocity blunt injuries (31%). The anatomic distribution of fractures evaluated was the angle (27%), symphysis (21.3%), condyle and subcondyle (18.4%), and body (16.8%). CONCLUSION This study helps provide and support the relation between several variables associated with many common traumatic injuries seen in the mandible. This analysis can be used to help surgeons identify and anticipate injuries based on age, gender, and mechanism of injury.

Fractures of the Growing Mandible

Oral and maxillofacial surgeons must constantly weigh the risks of surgical intervention for pediatric mandible fractures against the wonderful healing capacity of children. The majority of pediatric mandibular fractures can be managed with closed techniques using short periods of maxillomandibular fixation or training elastics alone. Generally, the use of plate- and screw-type internal fixation is reserved for difficult fractures. This article details general and special considerations for this surgery including: craniofacial growth & development, surgical anatomy, epidemiology evaluation, various fractures, the role rigid internal fixation and the Risdon cable in pediatric maxillofacial trauma. It concludes with suggestions concerning long-term follow-up care in light of the mobility, insurance obstacles, and family dynamics facing the patient population.

Facial skeletal trauma in the growing patient.

The management of pediatric craniomaxillofacial trauma requires the additional dimension of understanding growth and development. The surgeon must appreciate the considerable influence of the soft tissue envelope and promote function when possible. Children heal well but with an exuberant tissue response that may contribute to greater scarring, therefore, careful and prudent attention given to meticulous soft tissue repair and support is critical. Support must also be given and sought from the family of the injured child. Follow-up management of children must continue to ensure that the growth of the craniomaxillofacial skeleton continues within the normal parameters of development.

Contemporary management of infected mandibular fractures.

The treatment of infected mandibular fractures has advanced rather dramatically over the past 50 years. Immobilization with maxillomandibular fixation and/or splints, removal of diseased teeth in the fracture line, external fixation, use of antibiotics, debridement, and rigid internal fixation has played a role in management. Perhaps the most important advance was the realization that infected fractures also result from moving fragments and nonvital bone, not just bacteria. Controlling movement and eliminating the dead bone allowed body defenses to also eliminate bacteria. The next logical step in the evolution of treatment was primary bone grafting of the resulting defect following application of rigid internal fixation and debridement of the dead bone. We offer our results with this treatment in 21 infected fractures, 20 of which achieved primary union.

Surgical Management of a Giant Cavernous Hemangioma Involving the Lower Lip: Report of a Case and Review of the Literature

The patient was an 8-year-old girl with a 15 12 6-cm ongenital cavernous hemangioma (CH) involving the ower lip. It had increased in size with the growth of the hild, and at the time of admission, there was a marked rotrusion of the lower lip (Fig 1). On the mucosal surface, here was dark purple. The lower lip could not be closed, nd saliva drooled from the mucosal surface of the enlarged ower lip. The patient’s speech was thick and difficult to omprehend. Pressure from the size and weight of the nlarged lower lip had produced mandibular deformity, hich was characterized by an anterior open bite and nterior displacement and outward tipping of the incisal dges of the anterior teeth. A 3-dimensional computed toography (CT) scan showed extension of the lesion that nvolved the body of the mandible. Absorption of the lateral ortical plate of the mandible was observed (Fig 2). The atient was hospitalized for treatment. On the basis of the linical findings and a CT scan, a decision was made, to-

Craniofacial Dysostosis Syndromes: Evaluation and Staged Reconstructive Approach

Craniofacial Dysostosis Syndromes: Evaluation and Staged Reconstructive Approach Jeffrey C. Posnick, DMD, MD, Paul S. Tiwana, DDS, MD, MS, Ramon L. Ruiz, DMD, MD* Posnick Center for Facial Plastic Surgery, Chevy Chase, MD, USA Georgetown University Medical Center, Washington, DC, USA Department of Orthodontics, University of Maryland, Baltimore College of Dental Surgery, Baltimore, MD, USA Division of Oral & Maxillofacial Surgery, Department of Surgery, University of Texas Southwestern School of Medicine, Dallas, TX, USA Arnold Palmer Hospital for Children, 83 West Columbia Street, Orlando, FL 32806, USA University of Central Florida College of Medicine, Health Sciences Campus at Lake Nona, 6850 Lake Nona Boulevard, Orlando, FL 32827, USA