Australian Dental Journal

Australian Dental Journal The official journal of the Australian Dental Association Australian Dental Journal 2018; 63:(1 Suppl): S35 S47 doi: 10.1111/adj.12589 Current and evolving trends in the management of facial fractures N Vujcich, D Gebauer Oral& Maxillofacial Surgeon, Royal Perth Hospital, Perth, Western Australia, Australia. ABSTRACT The oral and maxillofacial region has a complex regional anatomy including hard and soft tissues. Trauma in this region may affect the airway, cause potentially life threatening bleeding and head injuries. The senses of olfaction, sight and hearing can also be disrupted as well as a profound psychological impact following disfigurement. This oral and maxillofacial trauma update provides information on demographics, incidence, pathophysiology, diagnosis, fracture patterns and management of facial trauma. It also discusses the role of new advancements in the management of facial trauma. Keywords: Le Fort, mandible, maxilla, maxillofacial, naso-ethmoidal complex, occlusion, orbit, trauma, zygoma. Abbreviations and acronyms: CAD = Computer assisted design; CAM = Computer assisted manufacture; CT = Computerised tomography; IMF = Intermaxillary fixation; MCT = Medial canthal tendon; MRI = Magnetic resonance imaging; NOE = Naso orbital ethmoidal complex; ORIF = Open reduction, internal fixation; RPH = Royal Perth Hospital. Accepted for publication October 2017. INTRODUCTION Maxillofacial trauma is classified into injuries involving the lower, middle and upper thirds of the face. It includes the soft and hard tissues of the face and oral cavity. Oral & Maxillofacial surgeons have played a major role in the evolution of facial trauma management, and are currently at the forefront of management and advances in these treatments. The majority of Australian oral and maxillofacial surgeons treat facial fractures as part of their practice. 1 Maxillofacial injuries occupy a spectrum of complexity. At one end are minor dentoalveolar injuries managed as an outpatient. Dental Traumatology has been fully presented in the 2016 Australian Dental Journal Supplement and will not be discussed further in this paper. 2 At the other end are multisystem, life threatening injuries requiring tertiary hospital admission, multidisciplinary treatment and complex reconstructive procedures. Central to managing these facial injuries is a strong dental education. Facial trauma may be life-threatening as a result of airway obstruction or haemorrhage. Longer term functional complications may arise including injury to vital sensory structures responsible for vision, olfaction, hearing and taste. Motor nerve and soft tissue injuries with scarring may impair facial expression, an important nonverbal form of communication. Psychological distress is common in those patients who suffer cosmetic deformity. Non anatomical repairs of underlying facial bones and associated soft tissues may also result in changes to occlusion and speech. Reconstruction of the oral cavity without consideration for dental rehabilitation will complicate the prosthetic outcomes following healing. Reconstructive goals in managing maxillofacial trauma include returning the patient to as close to their pre-injury status as soon as possible, and an early return to function. In cases of severe trauma, multiple surgical procedures may be may be required to achieve this goal. DEMOGRAPHICS Facial trauma is a frequent presentation in emergency departments, with the aetiology and fracture pattern influenced by the geographic region studied. In the adult group, facial fractures are usually the consequence of behavioural risk-taking. The majority are the result of interpersonal violence and motorvehicle accidents, and less so falls, sports, and workplace injuries. In the paediatric and geriatric groups, lower levels of co-ordination together with cognitive deficits are a greater cause of trauma than the behavioural issues seen in the adult group. 2018 Australian Dental Association S35

N Vujcich and D Gebauer Royal Perth Hospital (RPH) is the major tertiary trauma hospital in Western Australia and includes the State s Trauma Unit (excluding paediatrics). The average age of a patient treated for facial fractures in RPH during 2012 was 28 years, with a male dominance (87%). 3 Certain subgroups were over-represented, with 6% of all operative patients being prison inmates (0.1% of nations population 3 ), and 30% of all operative facial fracture patients being of Aboriginal descent 3 (3% of Western Australia s population) (Figs 1 and 2). 4 O Meara found that 53% of facial fractures were involved with recent alcohol use. 5 Other illicit drugs were also frequently, with 47% testing positive, and cannabis the most common drug involved. 6 Paediatric (<18) and geriatric (>65) populations are less likely to sustain facial injuries or require surgery in the event of such trauma. Paediatric fracture incidence increases with age, with 10% of fractures occurring in those under five, and increasing to 50% in the 15 18 year old group of paediatric patients. 7 Facial fractures occurring in older patients are usually associated with other significant injuries, greater severity and death. 8 The risk to benefit ratio in older patients influences operative decision making, often resulting in a lower operative rate (Fig. 3). FRACTURE PATTERN AND INCIDENCE Facial trauma classification is divided into vertical facial thirds. The upper third includes the frontal bone, the mid third includes the maxilla, zygomas, orbits, nose and naso-orbital ethmoidal complex whilst the lower third includes the mandible (Fig. 4). Lee reviewed data from more than 2500 patients treated by Oral & Maxillofacial surgeons in New Zealand over 10 years. 8 He found the incidence of facial third fractures with the lower third was 33.1%, middle third 63.5% and upper third fractures 3.3% (Fig. 5). 5 The proportion of operative cases of all facial fractures is shown in Figure 6. 3 Lee noted 53% of fracture patients required surgery whilst 47% did not illustrating differences between fracture incidence and operative cases. 8 50 45 40 35 30 25 20 15 10 5 0 19 (6%) 124 (41%) Residence of pa ents 18 (6%) 141 (47%) Fig. 2 Residence of patients. Perth Metropolitan Rural Western Australia Non Western Australian Inmate Percentage of opera ve facial fractures by age, RPH 3 <20 20s 30s 40s 50s >60 Fig. 3 Percentage of operative facial fractures by age, RPH 3 TRAUMA MANAGEMENT The initial management of facial trauma follows life support principles, as outlined by Early Management of Severe Trauma of the Royal Australasian College of Surgeons. 9 In the primary survey life threatening injuries are diagnosed and stabilized. Once the patient is stabilized, the secondary survey diagnoses other injuries. Maxillofacial trauma not associated with airway obstruction or major bleeding is treated after the patient is stabilized, as part of the secondary survey. The goals in managing facial trauma are 40 (13%) Sex Aboriginal Male 90 (30%) 212 (70%) Yes 262 (87%) Female No Fig. 1 Three hundred and two facial fracture patients operated on by the OMS team Royal Perth Hospital in 2015. 2 S36 2018 Australian Dental Association

Facial fractures I II III Fig. 4 Vertical facial thirds of the face. 35 30 25 20 15 10 5 0 70 60 50 40 30 20 10 Percentage of consulted facial fractures by individual bones Frontal Bone Zygoma Orbit Maxilla Nose NOE Mandible Fig. 5 Percentage of consulted facial fractures by individual bones. 8 0 Frontal Bone Percentage of opera ve facial fractures by individual bones Zygoma Orbit Nose Maxilla NOE Mandible Royal Perth Fig. 6 Percentage of operative facial fractures by individual bones. 3 Restoring anatomy and eliminating deformity Restoring occlusion and masticatory abilities Restoring function including nasal airflow and ocular function Minimising morbidity Early return to function Formal dental training provides the treating surgeon superior diagnostic abilities, improves surgical outcomes and enhances the post-operative management of facial trauma patients. Understanding occlusion is particularly important with respect to mandibular trauma, midfacial fractures, and pan-facial fracture sequencing. LOWER THIRD FRACTURES Mandible The mandible is one of the most common of all facial fractures, and has the highest surgical intervention rate of all facial bones. Classification is based on the anatomical location of the fracture. The most common sites are of the mandibular condyle, angle and parasymphysis whilst the body, coronoid and ramus are least frequent. 10 Mandibular fractures can result in malocclusion, inferior alveolar nerve paraesthesia, and ankylosis. Infection and osteomyelitis may occur in patients who have a delayed presentation. A Tasmanian study recently found that 68% of diagnosed mandibular fractures require treatment. 11 Early operative time (within days) is preferred as many are open fractures and painful due to mobility. Mandibular condyle fractures may be best left until oedema has resolved (several days), to simplify surgical access. Historical treatments involved wiring fracture segments and inter maxillary fixation or wiring of the jaws (IMF) into occlusion. IMF is maintained for 4 6 weeks and impairs feeding. It increases the risk of ankylosis and the potential need for tracheostomy. Closed reduction with IMF is still used in some cases, alone or combined with plating techniques. The use of arch bars with interarch elastics rather than wires guides the occlusion for 4 6 weeks. It does not prevent mandibular movement (Figs 7a c and 8). Current treatments involve repositioning and securing fracture segments with metal plates and screws and are termed open reduction and internal fixation (ORIF). Small strategically placed load-sharing plates are used to counter mandibular muscular forces, and distribute the force between the plate and mandible. This technique, developed in the 1970s, is based on theoretical tension bands, and resisting displacement when the mandible is loaded. These smaller plates provide semi rigid fixation, allowing a small degree of movement. 2018 Australian Dental Association S37

N Vujcich and D Gebauer (c) Fig. 7 (a, b, and c) An axial and reconstructed CT scan of a badly comminuted mandible, wired into rigid IMF (left lateral view) for closed reduction using a custom occlusal splint. This fracture was not amenable to open plating. Larger load bearing plates can provide absolute rigid fixation of fractures. They require greater surgical access and may be better suited to more comminuted fractures. The preference of plating technique depends on the surgeons training and both techniques can provide ideal outcomes (Fig. 9). There is some conjecture in the literature around the management of mandibular condyle, edentulous and paediatric fractures. Mandibular condyle fractures often present with posterior (unilateral fractures) or anterior (bilateral fractures) open bites. Historically, closed approaches with arch bars were used due to difficulty accessing the condyle for plating. Many authors now advocate open approaches, directly viewing the mandibular fracture of the condyle through a transfacial approach, and reduction and fixation with miniplates. The benefits include immediate return to function, and anatomical reduction (not achieved with IMF) providing a reliable means of securing the occlusion. This comes with the risks of facial nerve injury, sialocoeles, and a facial incision (Fig. 10). S38 Fig. 8 An example of surgical archbars with interarch elastics. Endoscopic techniques using mini-cameras have arisen to view and fix the mandibular condyle without significant facial incisions. This technique minimises the risk of facial nerve injury, but is technique-sensitive (Figs 11a and 11b). Plating materials originally included stainless steel which was superseded due to corrosion and difficulty of adaption difficulty. Current systems utilize titanium, which has better biocompatibility, handling and strength and is often left permanently in situ. It is nonferrous, and does not interfere with MRI protocols. Drawbacks of metallic fixation includes the possible need for removal due to loosening or exposure, concealment of underlying fractures on imaging, possible interference with growth and the query of stress shielding of bone, with local osteopaenia after fixation. For these reasons, research into resorbable plating systems has arisen (Fig. 12). Resorbable systems are fabricated from polymers, the properties of which influence the strength and resorption rate. These systems are generally not fit for load bearing scenarios. They maintain peak strength for around 3 months, before gradual hydrolysis over 1 2 years. Although promising, their handling properties, the presence of foreign body reactions and overall bulkiness, has precluded widespread support. MIDDLE THIRD FRACTURES The middle third of the face consists of many articulated bones, the most commonly fractured being the maxillae, zygomatic, nasal bones and orbital complex. Because of their proximity to the oral cavity, nasal cavity, orbit, and floor of the anterior cranial fossa, reconstruction is complicated due to limited access and complex local anatomy. Treatment goals are to correct the relevant occlusal, mid-facial, nasal and orbital anatomy whilst monitoring the base of skull for brain injury. 2018 Australian Dental Association

Facial fractures Fig. 9 (a and b) A badly displaced comminuted mandible (with previous fracture and unremovable hardware) repaired with a load bearing rigid plate. Fig. 10 Example of mandibular condyle fractures having undergone open reduction and internal fixation. These plates are examples of load sharing techniques. Whilst very strong, they do not provide absolute rigidity like the larger load bearing plates. MAXILLA Proposed at the start of the 1900s, the Le Fort classification (I III) is still the most commonly used in describing maxillary fractures The Le Fort I is a horizontal fracture above the tooth bearing portion of the maxilla. The Le Fort II is a pyramidal like fracture pattern involving the central mid-face, and the Le Fort III is craniofacial dysjunction, with the face detached from skull base. These fractures may not follow cleanly defined lines, and can vary between sides. The pathognomonic radiological sign on CT scan, is fracture of the pterygoid plates (Fig. 13). A higher amount of energy absorption is required to create a Le Fort fracture than other facial fractures, with over 80% of these fractures attributed to motor vehicle accidents. 12 Le Fort fractures have a higher association with other injuries, including cervical spine and head injuries. Patients may present with a flattened and mobile midface, anterior open bite malocclusion, and infraorbital nerve paraesthesia. Significant issues include profound epistaxis and cerebrospinal fluid rhinorrhea. The maxilla may also present as fracture of an isolated maxillary antrum, or in conjunction with a zygoma or naso-maxillary fracture. Historical treatment involved wiring either direct open interosseous wiring of the fragments, or closed circumosseous wiring, suspending the maxilla from upper intact facial bones. These techniques had limitations including facial shortening. Miniplate fixation in the maxilla evolved in the 1980s to provide rigid fixation, immediate function, and more predictable outcomes. Combination of open (ORIF) and closed (archbars) approaches are usually used in Le Fort fractures (Fig. 14). Maxillary fractures can be complicated by an additional split palate, which can cause transverse width issues. Treatment of such fractures utilizes orthognathic principles. Following impressions, the ideal occlusion is re-established by sectioning stone models into an ideal occlusion, and an occlusal splint is made. This is wired to the maxilla during reduction to correct the transverse width at the time of ORIF. It is kept in situ for 4 6 weeks post operatively (Figs 15 and 16). 2018 Australian Dental Association S39

N Vujcich and D Gebauer Fig. 11 An endoscope being placed through a transoral incision to view a condyle fracture. The screwdriver is then placed through a buccal (facial) stab to fixate the plates which were positioned via an incision inside the mouth. Fig. 12 (a and b) Plate exposure in the mandible 10 years after ORIF. I II III Fig. 13 ORIF Le Fort I, ORIF Le Fort II and ORIF Le Fort III illustrations of the three levels of the Le Fort midfacial facture patterns. (c) Fig. 14 Le Fort I level fracture on 3D CT, coronal views with fractured pterygoid plates, and (c) the repair with open reduction and archbars. S40 2018 Australian Dental Association

Facial fractures Fig. 15 3D reconstruction CT scan of a split palate, also seen on the axial CT scan views. Fig. 16 The patient's trauma model (bottom model) is sectioned and waxed into an ideal arch form and occlusion (top model), with a splint made and wired into the patient. ZYGOMA The zygomatic bone is the most vulnerable and thus frequently fractured mid-facial bone, due to its prominence in the face. It has 4 effective junctions with the skull; at the zygomatic arch, the zygomatico-frontal suture, the orbital rim and finally, at the zygomaticomaxillary buttress. It is these 4 regions that the treating surgeon must assess to determine the need for intervention. The depressed zygomatic complex causes a relative flattening on the injured side and therefore facial asymmetry. This may not be immediately evident due to facial swelling. Aside from these cosmetic consequences, if the zygomatic arch is severely depressed, it can restrict mouth opening. This is due to interference of the coronoid process on the mandible. Finally, the zygomatic bone makes up the lateral orbital wall and its injury can influence globe position and mobility. The 3 dimensional nature of the fractured zygoma makes them challenging to orientate in theatre. They are typically repaired either very soon after injury (before swelling), or in a delayed setting (after swelling). Surgical options include a lift reduction or ORIF. Isolated zygomatic arch fractures and non-comminuted zygomatic body fractures may be amenable to temporal elevation. Sir Harold Gillies was a New Zealand surgeon who first described the procedure for repositioning a zygomatic bone using an instrument via a small incision in the temporal hairline with no fixation (Figs 17 and 18). If the zygomatic complex is not stable after elevation, comminuted or unstable, or part of a pan-facial injury, it requires fixation. A fracture may receive fixation at one, multiple or all junctions of the zygoma. Miniplates and screws used in the midface are smaller than for mandibular trauma (Fig. 19). 2018 Australian Dental Association S41

N Vujcich and D Gebauer Fig. 17 A fractured left zygomatic arch on axial CT. A CT scan 2 years later after the original Gillies lift, after another assault. (c) Fig. 18 (a and b) A comminuted right zygomatic fracture with displacement at the arch, infraorbital rim, oral buttress and latral orbital wall. (c) Post op CT scans shown in comparison. ORBIT The orbit is a four-walled pyramid, with a floor, roof, medial and lateral walls. The incidence of these walls fracturing and their management is influenced by the patient age. In the adult group, the orbital floor is the most frequently fractured wall, due to its thin nature (<0.5 mm). It is followed by the medial wall whilst roof fractures are rare. Orbital wall fractures may result in cosmetic and functional deformity. The cosmetic issues include changes in the globe position leading to hypoglobus (lower eye) or enophthalmus (sunken eye). The functional issues involve entrapment of the extraocular muscles or adjacent tissues, limiting eye movement and leading to diplopia (double vision). Surgical access to the orbital walls is usually made around or within the eyelids. The orbital roof is usually accessed via a brow incision or intracranially via a coronal flap and craniotomy performed neurosurgically. Due to the thin nature of orbital walls, reduction and fixation is not feasible. After releasing tissues from the fracture defect, the wall is instead replaced with autogenous grafts (calvarium), xenografts S42 (resorbable collagen) or alloplasts (polyethylene, titanium mesh). Such materials are anatomically fashioned to the wall and secured to the orbital rims (Figs 20 and 21). Timing to repair fractured orbits typically follows a period of observation (1 2 weeks) before any operative decisions are made. Three-dimensional imaging has revolutionised orbital trauma management over the last 10 20 years. After computed tomography (CT) was introduced in the early 1980s, continued advances have included the introduction of intraoperative CT or cone beam imaging, enabling the surgeon to identify their reconstruction in theatre at the time. This minimises the risk of poorly positioned reconstructions and complications including blindness. CT can also be applied intraoperatively with real time navigation, permitting image guided surgery. The intraoperative position of the surgeon s instruments can be displayed on the CT and is useful in comminuted fractures or pan-facial trauma, assisting anatomical reduction. From preoperative CT, computer assisted design (CAD) and computer assisted manufacture (CAM) of models and plates have also evolved. Many larger tertiary hospitals now have bioengineering departments 2018 Australian Dental Association

Facial fractures (c) Fig. 19 Coronal and Sagittal (c) CT of right orbital floor blowout repaired with titanium mesh. Fig. 20 (a and b) Axial CT of right medial wall and orbital floor repaired with titanium mesh. (c) Fig. 21 Coronal CT of right medial wall and floor fracture. 3D orbital model from CT mirrored from normal left side. (c) Pre bent titanium mesh placed over the fractured model to confirm anatomy before surgery. capable of printing three dimensional stereolithographic biomodels from the CT. These may be used for Surgical planning, including assessing complexity and access Creating a mirrored model of the non-fractured side, enabling one to bend up a plate on the normal side and apply to the fractured side Creating a custom titanium plate to fit the defect exactly Such technology has also been utilized in orthognathic surgery and is becoming routine throughout Australia. The main difficulty in trauma is the time it may require to fabricate such plates and models in urgent cases (Fig. 22). 2018 Australian Dental Association S43

N Vujcich and D Gebauer Surgical correction of NOE fractures depends on bony displacement, and whether the MCT has been displaced. Measurements of the intercanthal distance will vary with age, sex and race. If the MCT has led to telecanthus, one must determine if repositioning the bones will correct the issue, or whether exploration, identification and securing of the MCT is required. This requires a significantly more complicated procedure, usually requiring a coronal flap (Fig. 23). UPPER THIRD TRAUMA Fig. 22 An example of bilateral NOE fractures. CENTRAL COMPONENT Naso orbital ethmoidal complex (NOE) This central component consists of the maxillary, nasal, frontal, lacrimal, and ethmoid bones. NOE fractures are not the same as external nasal bone fractures, which usually require a much simpler closed reduction. One complex aspect of NOE fractures is whether the medial canthal tendon (MCT), a ligament which supports the eyelids, is displaced. Displacement of the MCT leads to telecanthus, a lateralising of the medial aspect of the eyes, resulting in a broad nasal bridge. Frontal bone Frontal bone trauma is infrequent due to the significant strength of this bone. Further, the forehead is often protected by helmets in sporting and motor accidents, and is less likely to be targeted in assaults. Trauma to this site typically involves the frontal sinus, with fracture classifications based on involvement of the two walls of the frontal sinus that are the anterior and posterior tables (Figs 24 and 25). Decisions to operate are influenced by the presence of a cosmetic defect (i.e. depressed bone) or obstruction of the drainage apparatus (nasofrontal duct). Involvement of the anterior cranial fossa and dural tears may require a joint approach with neurosurgery. Unless a laceration has led to an open fracture, surgery is usually delayed from 1 to 2 weeks to permit swelling to subside to accurately assess the cosmetic defect. A coronal flap is folded over the brow to provide the necessary access and fractured segments are anatomically fixed using microplates or if markedly comminuted, mesh may be used. Trauma and improper reconstruction of the frontal sinus may lead to sinusitis, mucopyocoeles, meningitis and brain abscesses. (c) Fig. 23 3D CT reconstruction coronal and (c) axial views of an anterior table frontal sinus fracture. S44 2018 Australian Dental Association

Facial fractures camera. The fracture may be reduced and not require fixation, or mesh can be placed over the defect. It is secured using screws via separate transcutaneous stabs over the fracture. Fig. 24 A coronal flap raised to repair the frontal fracture as in Fig. 18. Note the face is on the upper aspect of the figure (hidden under the scalp), with the occiput on the bottom aspect of the figure. Raising a coronal flap itself has complications including scarring, facial nerve injury, temporal depression and paraesthesia of the frontal region. This has led to an endoscopic approach to repair anterior table fractures. This is done in a similar fashion to cosmetic brow lifts and is suited to large fragment anterior table fractures, not involving the posterior table nor the nasofrontal duct. Incisions are placed in the hairline, and subperiosteal dissection identifies the fracture using the endoscopic PANFACIAL FRACTURES Panfacial fractures denote simultaneous fractures of each level of the facial thirds. Such fractures imply a high velocity and force, and are more likely to be associated with injuries of the head and spine (Fig. 26). Often without reliable landmarks to begin reconstruction, pan-facial trauma requires a logical and ordered approach to achieve an ideal outcome. This process is referred to as sequencing. The sequence of bottom to top and outside in is a well-established approach. Restoring the mandible and occlusion first ( bottom ), ensures the vertical height of the face is corrected. The occlusion is therefore the basis for reconstructing the entire face. The maxilla is then wired into occlusion but not fixed. The zygomatic complex ( outside ) is then repaired ensuring the width of the face is corrected, before correcting the central component (NOE, in ), and finally plating the maxilla. Similar to an orthognathic surgical case, these patients are observed during their recovery with the use of intermaxillary elastics to achieve the operative occlusion. (c) (d) Fig. 25 Panfacial trauma in this case a split palate first (using custom splint, (c) usually begins with managing occlusion (d) before plating and reconstruction of the bones. 2018 Australian Dental Association S45

N Vujcich and D Gebauer Fig. 26 A bucket handle edentulous fracture, with the anterior mandible pulled down due to the pull of the suprahyoid musculature. After transcervical plating. A pan-facial trauma commences with managing the occlusion and split palate first, before plating and reconstruction of the midface and frontal bones. submandibular approach with a rigid reconstruction plate tends to be the preferred management option (Fig. 27). PAEDIATRIC PATIENTS Paediatric fractures are discussed elsewhere in this supplement. 13,14 GERIATRIC PATIENT Mandible The edentulous fracture is difficult to manage as it is associated with old age and often smoking, both risk factors for treatment failure. Elderly patients have decreased osteogenesis and limited blood supply. Atrophic edentulous mandibles have little room to place fixation, due to anatomical relationship to the mental foramen and denture bearing areas limiting plate locations. Historically, circumosseous wiring or wiring of a splint to the mandible was used to assist reduction, without lifting the periosteum in an open technique. Open reduction and internal fixation via a MIDFACE Atrophy in the edentulous maxilla, may make plating impractical due to very thin, often comminuted bone, which does not retain screws. Closed reduction may be appropriate in this case. Historically, wiring the patient into a bimaxillary or Gunning splint was used. In isolated mid-facial trauma, securing the maxilla to the undamaged mandible could maintain the correct anteroposterior position of the maxilla. If both jaws were fractured and the mandible not amenable to rigid fixation, the bimaxillary splint could be fixed to an external (skull) frame to maintain horizontal and vertical positions of the jaws for 6 8 weeks. Plating provides immediate function and is preferred, but plates must be kept away from the denture-bearing surfaces to avoid future impingements. An atrophic mid-facial fracture patient may have cleats added to his upper denture that is then screwed on to the maxilla, and then wired into intermaxillary (c) Fig. 27 (a and b) An edentulous midfacial facture patient where wiring of his occlusion is not possible. Limited plating of the right zygoma, floor of orbit and the left molar buttress. (c) Cleats are added to his upper denture which is then screwed to the maxilla enabling intermaxilliary fixation and correct positioning of the maxilla. The maxilla is then conventionally opened and plated. S46 2018 Australian Dental Association

Facial fractures fixation. This technique enables the correct AP position of the maxilla to be established. The maxilla is then conventionally opened and plated. CONCLUSION Facial trauma remains a major source of injury in all parts of the world. Its management involves many disciplines in the hospital setting, but knowledge of occlusion, the masticatory apparatus and anatomy that is part of the dental curriculum is important for the best outcomes. Oral & Maxillofacial surgeons are typically involved in the management of this trauma, and many of the patients will subsequently require further dental treatment following reduction of fractures. Hence, an understanding of the management of facial trauma and its sequelae is important for the general dental practitioner. ACKNOWLEDGEMENT Thanks are given to the Royal Perth Hospital Medical Illustrations team for their kind assistance in preparing diagrams for this article. REFERENCES 1. Ricciardo P, Bobinskas A, Vujcich N, Nastri A, Goss A. Survey of Australasian oral and maxillofacial surgeons 2011 scope and workforce issues. Int J Oral Maxillofac Surg 2015;44:1569 1573. 2. Abbott P. Guest Editor. The Management of Dental Trauma. Aust Dent J 2016;61(Suppl):82 94. 3. Royal Perth Hospital Audit Data, Oral & Maxillofacial Surgery Unit. 4. Australian Bureau of Statistics. Census 2011. 5. O Meara C, Witherspoon R, Hapangama N, Hyam DM. Alcohol and interpersonal violence may increase the severity of facial fracture. Br J Oral Maxillofac Surg 2012;50:36 40. 6. McAllister P, Jenner S, Laverick S. Toxicology screening in oral and maxillofacial trauma patients. Br J Oral Maxillofac Surg 2013;51:773 778. 7. Soleimani T, Greathouse S, Bell T, et al. Epidemiology and cause-specific outcomes of facial fracture in hospitalized children. J Cranio-Maxillofac Surg 2015;43:1979 1985. 8. Toivari M, Suiminen AL, Lindqvist C, Thoren H. Among patients with facial fractures, geriatric patients have an increased risk for associated injuries. J Oral Maxillofac Surg 2016;7:1403 1409. 9. Deane S. Early management of severe trauma - Royal Australasian College of Surgeons. ANZ J Surg 1991;61:809 813. 10. Lee K. Global trends in maxillofacial fractures. Craniomaxillofac Trauma Reconstr 2012;5:213 222. 11. Verma S, Chambers I. Update on patterns of mandibular fracture in Tasmania, Australia. Br J Oral Maxillofac Surg 2015;53:74 77. 12. Steidler NE, Cook RM, Reade PC. Incidence and management of major middle third facial fractures at the Royal Melbourne Hospital. A retrospective study. Int J Oral Surg 1980;9:92 98. 13. Heggie AA. Craniofacial disorders. Aust Dent J 2018;63: S58 S68. 14. Shand J. Paediatric oral and maxillofacial surgery. Aust Dent J 2018;63:S69 S78. Address for correspondence: Nathan Vujcich Royal Perth Hospital 197 Wellington St Perth WA 6000 Australia Email: nathan_vujcich@hotmail.com 2018 Australian Dental Association S47