Article: C. von See, A. Schramm, N.-C. Gellrich

One for All and All for One: improved wound treatment through interdisciplinary cooperation at a cranial centre

There have been significant changes with regard to the incidence, diagnosis and treatment of cranial injuries in recent decades. The factors underlying this are the growth in hazardous leisure activities, the fact that vehicles are travelling at faster speeds on our roads, a rise in violent crime and the modifications that have been made to the body armour used by service personnel deployed abroad. In the field, the facial region, in contrast to the torso and the neurocranium, is not protected by a flak jacket or helmet. As a result, there has been an over-proportional increase in the rate of casualties with facial injuries [1]. Treatment of this form of injury frequently requires close collaboration between a team of craniofacial specialists if function and appearance are to be satisfactorily restored following primary life-saving measures. It is for this reason that dedicated cranial centres have been established in civilian medical facilities. Such a cranial centre has now also been set up for the first time in a Bundeswehr hospital – the hospital based in Ulm. Working together here are the disciplines neurosurgery, neurology, otolaryngology (ENT), oral maxillofacial surgery, neuroradiology, ophthalmology and the various fields of dentistry, orthodontics and maxillofacial medicine. These collaborate in the preparation and implementation of cross-disciplinary diagnostics and treatment strategies. Surgical restoration of the dental, oral and maxillofacial regions is of central concern with regard to the subsequent quality of life of the patient. The involvement of dentists at an early stage of treatment is an essential requirement if the results are to be satisfactory in terms of function and appearance.

Introduction

Photo  Fig. 1: Post-operative layered-depth panorama view following surgical intervention in a mid-face and mandibular fracture Thanks to the introduction of standardised field casualty care protocols, such as the TCCC, the prognosis for casualties suffering severe cranial wounds has been appreciably improved. Many such patients who have been involved in military combat situations suffer multiple injuries, so that collaboration across the various disciplines when it comes to diagnosis and treatment is a given. An essential requirement during primary treatment is to determine the patient’s airways status. Tooth fragments, foreign bodies and dislodged prostheses can enter the respiratory tract and thus potentially cause complications. During the initial clinical examination, it is advisable to undertake a superficial inspection of the intraoral region in order to establish whether any teeth are missing or fractured, and how stable remaining teeth Photo  Fig. 2: Intraoral status following healing of initial surgery are. If there is any uncertainty in this respect, it is also prudent to prepare a radiological thoracic image to see if any teeth or tooth fragments have been aspirated. It should further be borne in mind that blood from visible bleeding from mouth and nose can be aspirated and that swelling of the soft tissues of the neck due to internal haemorrhaging can lead to stenosis of the airways. It is often not possible to undertake a detailed review of intraoral bleeding on the battlefield. The aim of primary treatment should thus be to still any bleeding by means of catheter embolisation and tamponade. 

A central element of subsequent diagnostic procedures in cases of cranial injury is the use of three-dimensional radiological imaging techniques in order to view the effects of the trauma. With the aid of multiplanar and three-dimensional reconstruction, it is even possible to ensure that less experienced colleagues are able to readily and succinctly grasp complex injury profiles. These techniques are vastly superior to two-dimensional imaging if it is necessary for the treating team to use telemedicine systems for communication. Hence, even if no specialist is available on the ground, the team can be effectively advised on treatment of complex cranial injuries by specialists at a cranial centre. The DICOM (Digital Imaging and Communications in Medicine) protocol is an internationally recognised standard that makes possible the transfer of radiological data irrespective of the imaging software and any possible language barriers. 

Photo Fig. 3: Status post exposure of implants to be used to fix the prosthesis There has been a tendency in recent years to delay the commencement of primary treatment following initial acute intervention and stabilisation of the patient because this is likely to result in a better outcome. Primary treatment is thus postponed until the patient has been repatriated to a facility where the various required specialists are available. In the cranial centre, it is decided in each individual case whether, for example, endogenous tissue should be used for reconstruction or a defect should be repaired using an epithesis. But not only the viability of the surgical procedure to be used needs to be considered – the psychological rehabilitation of the patient, who will often be traumatised by the facial injury, also needs to be planned. Although it is possible to achieve good aesthetic results using an epithetic approach in the case of facial defects [2], patient acceptance of this course of action is very low because of the resultant sensation of the presence of a foreign body. Moreover, seasonally-related changes to skin colour can contribute to a less satisfactory aesthetic outcome. Hence, in most cases, reconstruction using endogenous body tissue is the strategy that is most commonly adopted. The unique situation in the craniofacial region, with its complex and Photo Fig. 4: Final status of the prosthesis following augmentation of the keratinised gingiva using a mucous membrane graft close interplay between soft and hard tissues that occurs nowhere else in the human body, is a factor that must also be taken into account. 

The use of enossal implants is a standard dental procedure for prosthetic or epithetic reconstruction. In addition to the problems associated with the effects of biomechanical forces, the sites at which implants emerge from soft tissue can represent potential weak points. Sufficient and adequately stable bone needs to be present at the site of insertion if an implant is to be successfully retained over the long term. Following complex reconstruction of the craniofacial region, it is frequently necessary to augment bone using autologous tissue in subsequent implant regions. 

Case histories

Patient 1 

Photo Fig. 6: Result after dental reconstruction The patient suffered a traumatic cranial injury while riding a bicycle. Primary intervention involved first stabilising a fracture of the patient’s lower jaw. The accident had resulted in the patient losing teeth and bone from the alveolar process in the anterior segment of the mandible. For purposes of restoration, it was decided to provide the patient with an implant-based prosthesis. As direct implantation in the damaged area was not possible because of the lack of bone and soft tissue (Figs. 1 and 2), bone reconstruction was initially undertaken. Following a bone healing period of 6 months, the dental implantation procedure was initiated (Fig. 3). A further healing period of 4 months was observed, after which the implants were exposed and the prosthesis attached (Figs. 4 and 5). As there was no longer any keratinised gingiva present around the implants, it was necessary to reconstruct the floor of the mouth using a split-thickness graft taken from the maxilla. From both the functional and aesthetic viewpoints, the screw-fixed prosthesis represents the best possible solution for the young patient (Fig. 6).

Patient 2

Photo Fig. 5: Layered-depth panorama view of implants and prosthesis in situ The patient presented with a progressive neoplasm in the maxillary region (Fig. 7). The biopsy sample confirmed the diagnosis of squamous cell carcinoma. In the following consultation at the cranial centre, surgical resection of the tumour was recommended. Following successful resection and a relapse-free interval, plans for oral rehabilitation were made in view of the fact that the patient was unable to chew properly and was complaining of difficulties with swallowing (Fig. 8). This was mainly attributable to the fact that large areas of the maxilla had had to be removed because of the size of the tumour. Extensive augmentation seemed problematic in view of the general status of the patient, who was generally debilitated and experiencing psychological stress. The approach adopted was thus to use so-called zygomatic implants in the defective region (Fig. 9) and conventional dental implants following local bone augmentation of the maxilla on the contralateral side using material from the mandible, on which the maxillary prosthesis was fixed using an individually designed splint (Figs 10 and 11). The prosthesis thus provided is adequate to dealing with the defect and has significantly improved the quality of life of the patient. 

Discussion

Photo g. 7: Intraoral status: histologically confirmed squamous cell carcinoma Cranial injuries are frequently life-threatening. Although the head only constitutes 12% of total body surface area, injuries to the skull represent an over-proportional fraction of the wounds suffered by combat personnel. More than 40% of fatal battle injuries incurred in the Second World War and Vietnam conflict were attributable to head wounds. Improvements to the designs of military helmets have resulted in a reduction of the incidence of fatal cranial wounds. Helmets made of plastic laminate materials also markedly diminish the effects of airborne objects and shrapnel, with the result that penetrating wounds to the head have now become the exception [3]. During Operation Desert Storm, 80% of personnel who suffered cranial injuries were wearing a helmet at the time [4]. Nevertheless, 61% of the total casualties had a wound to the head. The high incidence of head wounds is attributable, among other things, to the increasing use of improvised explosive devices (IEDs), which more often cause wounds to head and neck, while the objects propelled by the force of an IED blast also injure the head/neck region and upper extremities significantly more frequently [5]. In nearly 50% of cases of facial injuries, the wounds are superficial. The second most common cause of head injuries after combat is road accidents of the kind that also occur in the homeland. In addition, one third of casualties suffer multiple injuries and penetrating wounds by foreign bodies. These can represent a particular challenge when it comes to subsequent reconstruction as they introduce contamination into wounds and prevent wounds healing. Interdisciplinary cooperation is nearly always necessary to achieve the rehabilitation of such patients [6]. The dental treatment of patients in this group also plays an important role. A fixed prosthesis based on implants is more widely accepted by patients and provides for an optimal solution in terms of appearance and promotion of their psychosocial reintegration. In addition, these devices augment the activities of swallowing and speech formation, and thus considerably enhance the general well-being of patients. 

Photo  Fig. 9: Intraoperative status during insertion of the zygomatic implants Facial injuries not only result in loss of functional abilities, but also in significant psychological problems because of appearance-related deficiencies. In their study, Levine et al. found that facial injuries that result in visible scar formation led to a significantly increased incidence of PTSD and alcoholism in comparison with a control group [7]. In general, individuals with injuries or malformations in the facial region encounter a negative social response in their environment. Not only that, but any remaining defect reminds patients of the traumatic incident itself, an effect that can also make psychological treatment necessary [8]. For complete rehabilitation, social assimilation and reintegration in the routine world of work are thus essential prerequisites.

Photo Fig. 8: Status post tumour resection and reconstruction of soft tissue Modern imaging techniques make it possible to precisely map the bony structures of the craniofacial region. With the help of all specialised disciplines at a cranial centre, it is thus possible to undertake virtual planning using models. This results in the improvement of treatment outcomes thanks to collaboration between the various specialists involved. It is only possible to predict in advance the results of reconstruction in each individual case if the core skills available at a cranial centre cover all necessary disciplines.


Date: 04/25/2018

Source: MCIF 3/2011