Robert D. Marciani

Management of frontal sinus fractures: a review of 33 cases.

PURPOSE The purpose of this article is to provide an overview of fracture patterns, patient characteristics, and surgical approaches associated with frontal sinus fractures. The short- and long-term complications of frontal sinus fractures treated over a 20-year period are presented. PATIENTS AND METHODS The records of patients admitted to the University of Kentucky Medical Center from 1975 through 1994 with a diagnosis of frontal sinus fracture were reviewed. Fracture patterns were categorized and information collected related to demographics, circumstance of injury, perioperative management, surgical procedures, and complications. Long-term complications were studied by asking patients to return for clinical and radiographic follow-up. RESULTS The average age of patients with frontal sinus fractures was 32 years. Thirty-one of the 33 victims were male. Motor vehicle accidents were the most common cause. Twenty-one patients had anterior table fractures (type I), 11 had combined anterior/posterior table fractures (type II = 9, type IV = 2), and one patient had an isolated posterior table fracture (type III). Short-term postoperative and perioperative complications were minimal. Long-term complications included acute frontal sinusitis (one patient), cosmetic forehead defects (two patients), and encephalitis (one patient). CONCLUSIONS The critical elements to successful frontal sinus fracture repair are precise diagnosis of the craniofacial fracture pattern, appropriate management of the frontonasal duct(s), and prevention of serious brain sequelae. Long-term follow-up of patients with frontal sinus injuries is recommended.

Osteoradionecrosis of the jaws

One hundred nine cases involving patients who had received radiation therapy for head and neck cancer were reviewed. Osteoradionecrosis of the mandible developed in only three patients in this group. Postirradiation extractions were not identified as a significant risk factor for such necrosis.

A survey of resident selection procedures in oral and maxillofacial surgery

PURPOSE This study was conducted to analyze the current procedures used in oral and maxillofacial surgery resident selection, to compare these selection procedures with those used 2 decades ago, to determine whether any differences exist in the selection procedures between 4-year certificate programs and programs that offer formal medical education, and to provide criteria to assist in the counseling of dental students on the application process for oral and maxillofacial surgery residencies. SUBJECTS AND METHODS Questionnaires were sent to the 106 oral and maxillofacial surgery graduate training programs accredited by the American Dental Association. To provide for a more direct comparison to the study completed in 1976, the current questionnaire was developed, using the original survey as a model. It was divided into 5 sections: general information, information obtained from the formal application and letters of recommendation, the interview, the decision process, and a retrospective view of past decisions. The results were tabulated and the Pearson chi-square test was used to determine statistical significance when comparing the 4-year certificate programs to the programs that offer formal medical education. RESULTS Seventy-one responses (75.5%) from nonmilitary programs were returned and analyzed. Thirty-nine responses represented dual-degree (MD) programs. Factors that were considered very important when judging a candidates written application included dental school class rank (76.1%), dental school basic science grades (70.4%), and dental school clinical grades (63.4%). Dual-degree programs placed a greater emphasis on predental basic science grades (P < .01) and dental national board scores (P < .05). When asked about prior resident selection, 86.7% of the respondents said they would select 80% of their former residents again. In addition, 89.9% of the respondents were satisfied with their current selection process. CONCLUSIONS The procedures used to select oral and maxillofacial surgery residents are relatively constant among programs. Although the dual-degree and 4-year certificate programs use the same criteria for resident selection, the dual-degree programs place greater emphasis on predental academic performance and on the results of the national dental boards. Criteria used 22 years ago to select residents are still applicable, but there has been a shift in the importance of some variables.

Autologous transfusion in orthognathic surgery

The principles of autologous transfusion are discussed. Autologous blood can be transfused for about the same cost as conventional donor blood, but there is decreased risk of the transmission of infectious disease or the formation of antibodies directed against red-cell antigens. Intraoperative blood replacement requirements for almost all orthognathic surgical procedures may be met by autologous liquid storage according to the schedule provided.

Principles of management of complex craniofacial trauma

Successful treatment of patients with complex craniofacial injuries is heavily dependent on the surgeons appreciation of the associated nonfacial injuries, precise clinical and diagnostic imaging examinations to establish a three-dimensional configuration of the fractured segments, and the application of well-established principles of facial fracture repair. Factors that influence improved treatment outcome are 1) early definitive treatment, 2) anatomic and functional repair of naso-orbito-ethmoidal injuries, 3) wide exposure of fracture segments, and 4) anatomic repositioning and stable fixation of fracture segments in all planes of space.

Management of midface fractures: fifty years later.

Much has changed in the 50 years since Dr Parker described the development of rapid means of transportation as a portent of an increase in maxillofacial trauma. Contemporary surgeons must concern themselves with a host of nonsurgical care issues that are an integral part of oral and maxillofacial surgery practice. Expectations related to the patient, government, insurance carrier, and hospital staff have created a new practice environment. Standards of care are high and surgeon and patient needs are more complex. Dramatically improved diagnostic capabilities, use of open surgical techniques, improved rigid fixation devices, advances in techniques of resuscitation, and more focused surgical training have markedly improved the care of the facial trauma patient. The midface remains the central focus of our gaze when we engage in interpersonal relationships. Developmental and acquired aberrations of this region are likely to be more obvious than lower face abnormalities and, therefore, perceived as more disfiguring. Complex midface trauma repair requires precise surgical technique, with little margin for error. When ideal results are not achieved, the common contributing factors are intercurrent serious injury, anatomic and wound repair considerations, and failure to execute fracture repair principles. Hard and soft tissue volume changes may further compromise midface fracture repair, irrespective of the quality of the surgical outcome. Despite the advances made in the last 50 years, there is still room for future progress. An interdisciplinary committee of surgeons treating facial trauma should convene to establish a classification system for midface fractures that would satisfy medical record keeping and coding requirements, and facilitate fair and consistent reimbursement.(ABSTRACT TRUNCATED AT 250 WORDS)

Patient compliance—A factor in facial trauma repair

The clinical records of 25 consecutive patients who were treated for facial trauma were reviewed and analyzed to ascertain what effect patient cooperation had on the outcome of facial fracture repair. The study was designed to establish the incidence of complications and to discover what factors contributed to untoward sequela in such patients. Overall, 15 patients (60%) were noncompliant in one or more aspects of their care. Six patients (24%) had significant postoperative complications associated with their facial injuries. Four of these patients were not fully cooperative.

Critical systemic and psychosocial considerations in management of trauma in the elderly.

Traumatic injuries in the elderly are increasing commensurately with the activeness and healthiness of the lifestyles seen in our expanding geriatric population. Census data suggest that the elderly population will expand by 50% in future years and will represent a larger percentage of Americans by the year 2050. The annual occurrence of traumatic injuries in the elder cohort is reported to be as high as 29%. Perioperative management of acutely injured elderly patients is different from the care rendered to younger patients and is typically more complex. The purposes of this article are to (1) review factors related to aging that may have profound effects on the care and outcomes of senior citizens with craniofacial trauma, (2) consider the perioperative medical evaluation of the older patient, (3) discuss nutritional support and anesthetic management in the elderly, (4) discuss the unique physiological factors that may influence the treatment of craniofacial trauma in older patients, and (5) provide a rationale for facial trauma repair in the elderly that is influenced by the risk-benefit outcome of treatment planning decisions.

Outcomes of Mandible Fracture Treatment at an Academic Tertiary Hospital: A 5-Year Analysis

PURPOSE To analyze the outcomes of mandible fractures treated using open reduction and internal fixation. PATIENTS AND METHODS We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded. RESULTS Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495). CONCLUSIONS A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.

Treatment of facial fractures in neurologically injured patients

The clinical records of 53 patients who had head injury and facial trauma were reviewed and analyzed to ascertain what affect head injury had on the repair of facial fractures. The study was designed to establish the incidence of complications and to discover what factors contributed to untoward sequela in such patients. It was found that the neurologically injured patient developed postoperative facial fracture complications, particularly in the mandible, more frequently than those facial trauma patients who were not neurologically compromised.