Man Hit by Truck.

SavageGlow · #1 ● 03-26-2023, 09:27 PM

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A 53-year-old man was presented to the emergency department of Shahid Beheshti hospital in Babol, Iran, following a motor vehicle accident involving the patient getting hit by a high-velocity lorry as he was crossing the street. Upon presenting to the emergency department, neurological and surgical evaluations were done and intracranial, cervical spine, thoracic, abdominal, and other severe extremity injuries were ruled out. He had sustained soft tissue lacerations extending from supraorbital regions to upper lip with almost complete destruction of nasal structures and hemorrhage (Figure 1). Furthermore, intraoral examinations revealed intact maxillary edentulous and mandibular partially edentulous ridge. A computerized tomography (CT) scan with three-dimensional reconstruction was prompted and it further depicted the extent of the injury. No concomitant injuries in upper and lower extremities were observed. Preoperative laboratory tests revealed normal findings.

Regarding CT scan analysis, left orbital floor was completely comminuted. Furthermore, bilateral pterygoid plates fractures and bilateral comminutions of zygomatic buttresses and frontal walls of maxillary sinuses extending to inferior orbital rim and nasofrontal suture were observed. Fractures in left zygomatico-sphenoid and zygomaticofrontal suture and left zygomatic arch were depicted. Also, CT scan imaged a Naso-Orbito-Ethmoidal (NOE) fracture. Moreover, a unilateral coronoid process fracture just above the mandibular notch was noted on the right side. Final diagnosis for the patient consisted of Lefort II, left zygomatico-maxillary complex (ZMC), NOE type 3b, left orbital blow-out, and right mandibular coronoid fractures [21] (Figure 2).

Patient went under general anesthesia through submental endotracheal intubation. Surgical access was obtained through expansion of existing lacerations for visualization of underlying skeletal structures. Following a thorough and rigorous irrigation with saline, airway patency was maintained using two nelaton catheters in nostrils (Figure 3). After a laborious 9-hour surgery, comminuted structures including left orbital floor and bilateral frontal walls of the maxillary sinus were reconstructed by titanium mesh plates and the remaining fractured structures were reduced and fixed using microplate and screws in an outside-to-inside fashion and a primary stabilization of mid-facial structures was obtained. Both eyes were salvaged. Suturing of the lacerations was accomplished except the nose with the nelaton catheters inside the nostrils. Nelaton catheters were removed and suturing of the nose was completed in final stage. Postoperative clinical image and 3D-reconstructed CT scan are shown.

He was admitted for seven days in the hospital and then subsequently discharged. During postoperative period, no complications including infection, wound dehiscence, or retrobulbar hemorrhage were reported.

Ocular examination after surgery revealed anisocoric. Normal findings in the right eye and decreased vision accuracy in the left eye were reported.

Following a year after the initial surgery, the patient referred to us seeking rehabilitation of the edentulous areas in his mouth. He used a maxillary complete denture and mandibular partial denture that were broken in the accident. Cone beam computed tomography (CBCT) and orthopantomogram (OPG) were then obtained which revealed inadequate bone width in the maxilla and therefore necessitating a crestal bone augmentation and bone grafts. Initial treatment plan consisted of fixed implant prosthesis on maxilla and removable overdentures in the mandible. Oral rehabilitation was scheduled for this patient in three stages. In the first stage and under general anesthesia, the reconstruction of maxillary atrophic ridge was done using autogenous bone graft harvested from anterior iliac spine. The remaining four mandibular teeth were then extracted and 4 implants (Osstem® fixture, TS III SA) inserted immediately during this stage. During the healing period, no infection, wound dehiscence, or tenderness was observed on the graft recipient or donor sites. After 6 months, patient recalled for implant insertion with a new CBCT of augmented sites. Therefore, 8 maxillary implants (Neodent® Acqua Drive) were inserted in augmented sites. After a few early follow-up sessions, the patient decided to have a fixed prosthesis for the mandible as well, therefore, 3 additional implants (Osstem® fixture, TS III SA) were placed in the mandible . After 4 months, maxillary and mandibular fixed prosthesis was delivered to the patient.