In severe maxillofacial injury due to HET, prompt cooperation between the primary survey and the specialized departments concerned with the adjacent affected organs is required. In cases where specialized diagnosis and treatment are required to manage systemic and oral/ maxillofacial injuries, it is beneficial to include an oral and maxillofacial during the treatment planning 1). Multiple maxillofacial injuries result in loss of alveolar mucosa in addition to jaw bone fractures and missing or damaged teeth. Dental implants are effective in restoring the aesthetic and oral functions 2,3). However, the reconstruction process requires a long treatment period and many surgeries. There are several advantages of including a maxillofacial surgeon for the occlusal reconstruction during the treatment planning. In the absence of any issues with life support, it is important to consult with adjacent medical specialists, such as brain surgeons, ophthalmologists, and otolaryngologists to start the diagnosis and treatment planning for the middle and lower thirds of the face. The major goals of treating maxillofacial fractures are to restore the midface’s symmetry and the mandible’s continuity. It is important to follow evidence-based treatment strategies 4) for good results with maxillofacial fracture treatment.
Occlusal reconstruction is the main theme of stomatognathic medicine. It begins 6 months after mandibular fracture following confirmation of the absence of disorders in the temporomandibular joint. It is desirable for this medical team to be able to organically collaborate with the oral surgery team responsible for jawbone fractures, the prosthetic team for restoring the dentition and occlusion, and the periodontal team for improving the periodontal environment. Dental implant treatment aims to match morphological aesthetics with functionality. In order to achieve the maximum effects of the implant in terms of occlusal reconstruction, it is important to assess the condition of the periodontal tissues and place the osseointegrated implant in the appropriate position 5). Therefore, the use of 3D digital images is useful during treatment planning.
The minimum bone width and height of the alveolar ridge for dental implantation must be > 5 mm and > 10 mm, respectively 6). Reports on the use of distraction osteogenesis, autologous bone grafting 7), titanium mesh tray, and iliac particulate cancellous bone and marrow transplantation (Ti-MESH method) 8,9) for bone defects have been published in the literature. The advantage of distraction osteogenesis is that the soft tissue can concurrently be expanded; however, the dynamic treatment period of several months is a major drawback. In the Ti-MESH method, the biggest concern is the surgical invasion of the ilium crest. Expected results may not be obtained due to the titanium mesh’s adverse events (tray exposure and increased risk of infection) and remodeling resorption, leading to loss of the graft 10,11). Bone grafting is considered optimal for complex and extensive bone loss due to trauma. Autologous bone grafting, which has excellent bone formation ability, is the gold standard for bone regeneration. Since the donor site’s structure and anatomical site may affect the outcome of the bone graft 12), the recipient site should be closer to the donor if possible. Bone graft planning requires a 10–20% increase in target bone regeneration owing to the resorption of the graft bone.13). It has been reported that the amount of the grafted bone absorbed is less in the mandible generated through intramembranous ossification than in the iliac crest generated through endochondral ossification.14,15). The chin bone is highly calcified, which helps to make an early transition to the mandible 16). In addition, the cortical bone with its high mineral density is useful for providing the primary stability for the dental implants. We are selected the recipient sites according to the requirements of the donor. In the this case study, the chin’s cortical bone was selected because it could be collected from the same surgical field. The use of chin cortical bone may be useful when grafting a bone to address a few alveolar bone defects.
The keratinized mucosa in the alveolar ridge is often lost along with the alveolar bone following a jaw fracture. Alternatively, a scarred mucosa remains after several surgical procedures. The mobile non-keratinized mucosa around the dental implant is more likely to cause peri-implantitis 17). Also, the development of a mucosal scar with poor blood flow is disadvantageous for bone formation. The presence of keratinized mucosa around the dental implants affects the long-term prognosis of the implant treatment 18,19). Therefore, vestibuloplasty and free gingival grafts to acquire a keratinized mucosa 20) are required. The palatal mucosa or atelocollagen is effective as a recipient of mucosal grafts 21,22). It is important to ensure that a keratinized mucosa (of 2 mm) is present around the dental implant. An oral photograph is indispensable because it is impossible to evaluate the soft tissues using X-ray photography or models. At present, it is unclear when the periodontal mucosa should be treated. The apically positioned flap technique is often performed at the same time as the secondary operation. However, oral mucosal defects after maxilla-orofacial trauma may require mucosal management before implant placement.
For patients with severe facial fractures, strict adherence to a well-established and structured treatment protocol based on surgical experience provides an efficient, appropriate, and successful treatment. Furthermore, superior results for severe traumatic maxilla-orofacial injuries will be achieved if the treatment is combined with efficient occlusal reconstruction.