Contemporary management of complex craniofacial trauma: virtual planning, navigation and the novel thermoformed cage splints in a strategic, sequential, computer-guided protocol

Complex craniofacial trauma has always represented a challenge for maxillofacial surgeons. Specifically, panfacial fractures represent the most complex situation owing to the simultaneous involvement of each subunit of the craniofacial skeleton, including the upper third, consisting of the fronto-orbital area, the middle third, including the zygomatic-maxillary region, and the lower third, represented by the mandible (Ali and Lettieri 2017). The effect of trauma forces mobilizes skeletal segments across fracture lines, significantly altering anatomical relationships of facial bones, which translates into the loss of esthetical proportions across multiple dimensions, including the anterior-posterior, lateral and top-bottom axes (Park et al., 2020). Frequently, references between displaced bones are missing, occlusal relationships are completely lost, and surgeons in the past had very ineffectual instruments, leaving the final result strictly dependent on personal experience and surgical sensibility. The approach to complex, multifragmented, displaced craniofacial trauma must be highly strategic, and in a contemporary vision, the same strategy can be applied to virtual surgical planning, a powerful tool, where a correct approach and surgical experience are fundamental as well for the success of the procedure. Virtual planning provides a simulation environment where surgeons can countlessly perform reduction of fractures, testing several strategies, and creating a three-dimensional template for reduction, which can be checked at any time using craniofacial navigation (Amundson et al., 2020). As a consequence of suboptimal bone realignment, final occlusion results altered, as even a slight malposition of skeletal parts can considerably modify occlusal contacts. Moreover, conventional techniques for occlusal restoration are outdated, as in many cases reestablishing the shape of dental arches requires to position arch bars with metal wires, a traumatic procedure that is time-consuming as well. Technology helped to overcome such issues using high-resolution imaging, intraoral scanning and digital occlusion, providing a substantial improvement in a surgical scenario that exclusively relied upon individual surgical experience.

It was the aim of the study to assess how computerized simulation is useful to plan cases of complex craniofacial trauma. Along with surgical planning navigation, the Authors also introduce the novel thermoformed cage splints as a beneficial innovation for immediate and accurate occlusal restoration.

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