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A Shattered Face:
Radiologic and Surgical Reconstructionof Complex Craniofacial Trauma
Kapil
Verma, Harvard Medical School Year IV
Gillian Lieberman, MD
May 2010
Beth Israel Deaconess Medical CenterHarvard Medical School
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Background: Epidemiology of craniofacial trauma• Approximately 50% of the 12 million annual traumatic wounds
treated in emergency rooms across the United States involve thehead and neck
• Common causes of craniofacial trauma include:-
Motor vehicle accidents (community setting)
-
Assault (urban setting)
- Sports injuries and falls-
Domestic violence
• Among level-1 trauma centers, facial trauma is managed by:
-
Plastic surgeons (40%)
-
Oral and maxillofacial surgeons (36%)
-
Otolaryngologists/head and neck surgeons (23%)
-
General surgery and Oculoplastics
(~0.5%)
Singer, Hollander, QuinnAksoy, Unlu, SensozBagheri et alHolmes
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Background: Why recognition and management of craniofacial
trauma is crucial
• The face contains crucial specialized systems needed to see,
hear, smell, breathe, eat, and speak
• Vital structures within the head and neck are intimatelyassociated
• Several facial injuries may be life threatening:- Hemorrhage-
Airway obstruction
- Aspiration
• The psychological impact of facial disfigurement can bedevastating
Manson et alLee et al
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Background: Clinical exam findings in the recognition of
craniofacial trauma
• Facial asymmetry
• Pain upon palpation
• Facial instability
• Cortical step-offs• Periorbital edema
• Periorbital crepitus
• Infraorbital numbness
• Epistaxis
• Epiphora
• Exopthalmus
• Enopthalmus• Telecanthus
• Orbital muscle/nerveentrapment
• Many more …
Manson et al
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Background: Limitations of the clinical exam in the recognition of
craniofacial trauma
Clinical evaluation of the facial skeleton in
trauma patients is difficult:- Facial features are often obscured anddistorted by endotracheal
and gastric tubes
and tapes that hold them in place. Thus,evaluation of facial instability is difficult
- Response to painful stimuli is blunted. Thus,evaluation of localized pain secondary tofractures is difficult
Rehm, Rhos
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Background: The crucial role of radiologic imaging in therecognition of craniofacial trauma
• Up to
60% of facial fractures may be missed
clinically (lack of step-offs, instability, orbitalentrapment, telecanthus, etc) and are later detectedby CT
• Of
those 60% of clinically unsuspected facial
fractures later detected on CT, approximately 50%require subsequent surgical repair
• As a result, though plastic surgeons andmaxillofacial surgeons primarily managecraniofacial trauma, the radiologist plays a crucial
role in diagnosis to guide management
Rehm, Rhos
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Normal craniofacial skeletal anatomy:
The skull consists of cranial and facial bones
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
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http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
Normal craniofacial skeletal anatomy:
Components of both cranial and facial bones form theorbit
-
colloquially known as the ‘eye socket’
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Normal craniofacial skeletal anatomy:
Lateral view of the 22 bones of the skull,8 cranial bones and 14 facial bones
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
8 cranial bones:
1 x Frontal
2 x Parietals
1 x Sphenoid2 x Temporals1 x Ethmoid
1 x Occipital
14 facial bones
2 x Lacrimals2 x Inferior Nasal Conchae1 x Vomer2 x Nasals2 x Zygomatics
2 x Palatines2 x Maxillae
1 x Mandible
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7 orbital bonesFrontal
SphenoidEthmoid
PalatineLacrimalZygomatic
Maxillary
Normal craniofacial skeletal anatomy:
Anterior view of the facial bones and orbit
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
14 facial bones
2 x Lacrimals2 x Nasals
1 x Vomer2 x Inferior Nasal Conchae2 x Maxillae
2 x Palatines2 x Zygomatics
1 x Mandible
Cranial
Facial
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Normal craniofacial skeletal anatomy:
Skeletal anatomy of the orbit
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
http://www.ophthobook.com/wp-content/uploads/2007/12/an-orbitbone.jpg
7 orbital bonesFrontal
Sphenoid
Ethmoid
PalatineLacrimalZygomaticMaxillary
Cranial
Facial
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Normal craniofacial skeletal anatomy:
Anatomy of the mandible
http://www.arthursclipart.org/medical/skeletal/skull%20front%20side.gif
http://www.face-and-emotion.com/dataface/anatomy/facialbones.jsp
Coronoid
process
Condylar process
Ramus
Angle Body Symphysis
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Shattered Anatomy: Intro to Patient AA
History
• 37M unhelmeted
bicycle rider struck by a car, propelled
head first through windshield
• Widely opened multiple cranial and facial fractures
with
visible brain material, otherwise (remarkably) no other
no traumatic injury to the chest, abdomen, or pelvis
• Intubation initially difficult secondary to multiple facial
fractures
• Unable to immediately assess for clinical signs of orbital
entrapment secondary to patient’s waning mental status
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Shattered Anatomy: Intro to Patient AA
Initial 3D Facial CT Reconstruction Anterior ViewNORMAL OUR PATIENT AA
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructions of the faceNormal patient on the left. Our patient AA on the right
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Shattered Anatomy: Intro to Patient AA Initial 3D Facial CT Reconstruction Oblique view
NORMAL OUR PATIENT AA
GE Vitrea 3D Workstation, MGH
Oblique 3D-reformatted CT reconstructions of the faceNormal patient on the left. Our patient AA on the right.
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Severely comminuted complexfrontal bone fractures
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Bilateral LeFort II fractures
Comminuted fractures of theethmoid
and sphenoid sinuses
nasal bone fractures
OUR PATIENT AA
Shattered Anatomy: Intro to Patient AA List of craniofacial injuries (to be revisited)
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructionof the face
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Menu of radiologic tests: Traditional facial radiograph series-
outdated in the
evaluation of facial trauma
• Traditional facial radiographic seriesinclude those such as the ‘Waters
view,’
‘Caldwell view,’
‘Towne view’
and submentovertex
view
• Such views are outdated
in
evaluation of facial trauma:
-
difficulty of interpretation
amongst non-radiologist
physicians-
inability to assess soft tissues
in detail
-
advent of CT and 3D CTreformatting
Chen, Ng, Whaites
http://www.ispub.com/journal/the_internet_journal_of_otorhi
nolaryngology/volume_5_number_2_21/article/inter_observ
er_and_intra_observer_variability_in_the_assessment_of_t
he_paranasal_sinuses_radiographs.html
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Menu of radiologic tests: Facial Multidetector CT - the imaging gold standard
• Facial Multidetector
CT without contrast with axial
and coronal sections is the gold standard
in the
evaluation of facial trauma
– Fast
– Bone windows may evaluate for fractures – Soft tissue windows may simultaneously evaluate for
secondary soft tissue swelling (including extra-ocularmuscles, nerves, and globe) and hematomas
– Coronal sections are superior to radiographs inshowing orbital floor fractures
– Subsequent 3D CT reformatting is possible
Tanrikulu, Erol
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Menu of radiologic tests:
CT with 3D reformatting - Background
• Contiguous 2D CT slices are obtained via
normal CT protocol
• These series of tomographs
are analyzed by
a 3D software program
• The computer essentially uses one of tworendered techniques to obtain a 3D image:
1-
Threshold/Surface Rendering
2- Volume RenderingKung, Fung
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Menu of radiologic tests: CT with 3D reformatting –
Surface rendering and
volume rendering
• Principle behind threshold/surface rendering is based onthe Hounsfield scale (quantitative scale for radiodensity
in
CT using Hounsfield Units = HU)
• Can select CT attenuation value of +150 HU as
threshold,
and thus all soft tissues (below +150 HU) excluded in final3D CT image, and only bone (and other structures withHU > +150) included
• Volume rendering performs a similar algorithm usingsummation
-1000 HU: Air -100-30 HU: Fat 0 HU: Water +30+100 HU: Soft tissue +1000 HU: Cortical Bone
Kung, Fung
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Menu of radiologic tests:
CT with 3D reformatting - Conceptually simplified
Combine withcoronal sections
Apply renderingalgorithmsusing HU
thresholdsto subtractsoft tissues
Axial CT sections obtained from PACS BIDMC; stacked graphic created independently3D CT Face reconstruction image obtained from GE Vitrea 3D Workstation, MGH
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Menu of radiologic tests: CT with 3D reformatting - useful for the surgeon
• Surgeons generally ‘think in 3D’ vs.
radiologists with specialized training in3D interpretation of 2D imaging
• 3D reformatting may aid in pre-surgicalplanning
• 3D reformatting may aid in the design ofcustom facial prosthetics
Reuben, Watt-Smith, Dobson, et alAlder, Deahl, Matteson
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Menu of radiologic tests:
Panorex
• 2D panoramic x-ray (radiograph) of the upper and
lower teeth and mandible
• Displays the mandible as a flat structure
• Combined with CT, picks up virtually all fracturesof the mandible
• When used alone, often misses parasymphysial
fractures
of the mandible
Romeo, Pinto, Cappabianca, et al
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Menu of radiologic tests:
Panorex – may miss mandibular fractures if used alone
Panorex film of the mandible, upper and lower teethAGFA, MGH
-This patient was initially
noted to only have 1 left nondisplaced
fracture at the
junction of the mandibular
ramus
and condylar
process
from this Panorex
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Menu of radiologic tests:
Panorex – may miss mandibular fractures if used alone
Panorex film of the mandible, upper and lower teethAGFA, MGH
-This patient was initially
noted to only have 1 left nondisplaced
fracture at the
junction of the mandibular
ramus
and condylar
process
from this Panorex
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Menu of radiologic tests: Panorex
–
should be used in conjunction with CT for
the evaluation of mandibular
fractures
-
On subsequent CT, however, in addition to known left mandibular
fracture, she was found to have 2 additional mandibular
fractures: a
right condylar process fracture, and a parasymphysial fracture
AGFA, MGHCoronal C- CT sections through mandible
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Menu of radiologic tests: Panorex
–
should be used in conjunction with CT for
the evaluation of mandibular
fractures
-
On re-evaluation of original Panorex, the 2 additional fractures seen onCT became apparent, though still difficult to assess on Panorex
alone
Panorex film of the mandible, upper and lower teeth
AGFA, MGH
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The patient subsequently had arch bar placement and
wire fixation of her maxillary and mandibular teeth
Panorex
film of the mandible, upper and lower teeth; post arch bar placement and wire fixation of upper
and lower teeth
AGFA, MGH
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Severely comminuted complex
frontal bone fractures
OUR PATIENT AA
Patient AA revisited: Frontal bone fractures
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructionof the face
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Patient AA revisited: Frontal bone fractures on CT
AGFA, MGH
Axial C- CT through the level of the frontal bone; bone window
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Patient AA revisited: Frontal bone fractures on CT, Findings
AGFA, MGH
Axial C-
CT through the level of the frontal bone; bone window
• Numerous severelycomminuted fractures ofthe frontal bone
• Low attenuation areas of
subcutaneous emphysema
• High attenuation foreignobjects, likely lead-
containing glassfragments (as patient wasprojected head firstthrough windshield)
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R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
OUR PATIENT AA
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructionof the face
Patient AA revisited: Orbital rim, wall, and floor fractures
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Patient AA revisited: Orbital fractures on CT
Coronal C- CT through the level of the orbits; bone window Sagittal C- CT through the level of left orbit; bone window
AGFA, MGH
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Patient AA revisited Orbital fractures on CT, Findings
• Non-orbital fracture seen: Depressedskull fragment of frontal bone (on softtissue window seen to cause cerebraledema, necessitating subsequentcraniectomies
and ventriculostomy)
• Complex displaced fracture of the rightsuperior lateral orbital rim
• Non-displaced fracture of the left lateralorbital wall
• Bilateral comminuted orbital floorfractures
• Depressed orbital floor fracture on theright
Coronal C-
CT through the level of the orbits; bone window
Sagittal C- CT through the level of left orbit; bone windowAGFA, MGH
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Patient AA revisited: Orbital injury on CT, soft tissue window
Coronal C- CT through the level of the orbits; soft tissue window AGFA, MGH
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Patient AA revisited: Orbital injury on CT, soft tissue window findings
Coronal C- CT through the level of the orbits; soft tissue window
• Extra-ocular muscles withinorbit
• Downward herniation
of
perioribital
fat (HU: -60)
into right maxillary sinus
• Blood
in bilateral maxillary
sinuses
• No evidence of optic nerveor extraocular
muscle
entrapment seen onsubsequent clinic exam(PERRL; negative forcedduction test)
* *
AGFA, MGH
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Bilateral LeFort
II fractures
OUR PATIENT AA
Patient AA revisited:
Bilateral LeFort II fractures
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructionof the face
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Patient AA revisited:
Bilateral LeFort II fractures on CT
AGFA, MGH
Axial C-
CT through the level of sphenoid; bone window Coronal C-
CT through the level of the maxilla; bone window
P tie t AA e i ited
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Patient AA revisited:Bilateral LeFort
II fractures on CT,
Findings
• Bilateral fractures of thepterygoid
processes of
the sphenoid (defines allLeFort
maxillary
fractures)
• Bilateral medial orbital
wall fractures resultingin pyramidal pattern ofthe LeFort
II fracture
Coronal C- CT through the level of the maxilla
Axial C-
CT through the level of sphenoid
AGFA, MGH
Patient AA revisited:
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Comminuted fractures of theethmoid
and sphenoid sinuses
nasal bone fractures
OUR PATIENT AA
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructionof the face
Patient AA revisited: Comminuted fractures of the ethmoid
and sphenoid
sinuses, nasal bone fractures
Patient AA revisited:
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Patient AA revisited: Comminuted fractures of the ethmoid
and sphenoid
sinuses, nasal bone fractures on CT
Axial C-
CT through the level of the ethmoid
and sphenoid sinuses Axial C-
CT through the level of the nasal bones
Bone window
Bone window
Patient AA revisited:
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Patient AA revisited: Comminuted fractures of the ethmoid
and sphenoid
sinuses, nasal bone fractures on CT, Findings (withblood
in both sinuses)
Axial C-
CT through the level of the ethmoid
and sphenoid sinuses Axial C-
CT through the level of the nasal bones
Bone window
Bone window
*
*
AGFA, MGH
d
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Severely comminuted complexfrontal bone fractures
R. superior lateral
orbital rim fracture
L. lateral orbital wall fracture
Bilateral orbital floor fractures
Bilateral LeFort II fractures
Comminuted fractures of theethmoid
and sphenoid sinuses
nasal bone fractures
OUR PATIENT AA
Patient AA revisited: Summary of all fractures
GE Vitrea 3D Workstation, MGH
Anterior 3D-reformatted CT reconstructionof the face
d
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Patient AA revisited: Follow-up
Anterior 3D-reformatted CT reconstruction of the facepost bifrontal craniectomies with ventriculostomy tubeplacement, and ORIF of comminuted frontal sinus fractures
OUR PATIENT AA POST-OP
GE Vitrea 3D Workstation, MGH
• Due to elevatedintracranialpressure, underwent
bifrontal
craniectomies
• Left ventriculostomytube was placed
• ORIF of frontal sinusfracture
d
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Patient AA revisited: Post craniectomies
and ventriculostomy
tube imaging
Oblique 3D-reformatted CT reconstruction of the face
post bifrontal
craniectomies
with ventriculostomy
tubeplacement
Sagittal
C-
CT Head post bifrontal
craniectomies
with
ventriculostomy
tube placement
GE Vitrea 3D Workstation, MGH
AGFA, MGH
Patient AA revisited:
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Patient AA revisited: List of subsequent craniofacial reconstructive
procedures
• Bilateral arch bar placement with intermaxillary
fixation
• ORIF of right zygomaticofrontal
suture
• ORIF
of right orbital floor fracture with
reconstruction of the floor with alloplastic
implant
• ORIF
of bilateral LeFort
II fractures
• Closed reduction of the nasal fractures
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Agenda
Background
Normal craniofacial skeletal anatomy Shattered anatomy: Intro to patient AA
Menu of radiologic tests Patient AA revisited
Conclusions
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Conclusions
• Craniofacial trauma can be devastating
if not acutely
recognized and managed
• The recognition of craniofacial trauma depends heavily onradiologic imaging since the clinical exam is unreliable (60%of facial fractures are missed clinically)
• Facial CT is the gold standard in the evaluation of facialtrauma: facial radiographs are outdated, except for Panorex
which
still has utility when used in conjunction with CT in the
evaluation of mandibular
fractures
• 3D CT reconstructions provide
useful information in surgical
planning
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Acknowledgments
• Gillian Lieberman, MD
• Yoon S. Chun, MD• Hillary Kelly, MD
• Gregory Czuczman, MD• David Li, MD
• Maria Levantakis• Linda Burke
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Bagheri
SC, Dimassi
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A, et al. Facial Trauma Coverage Among Level-1 Trauma Centers of the
United States. J Oral Maxillofac
Surg. 2008; 66(5):963-7
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Holmes S. Facial Trauma –
who should provide care? Br J Oral Maxillofac
Surg. 2009; 47:179-81
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Aksoy
E, Unlu
E, Sensoz
O. A retrospective study on epidemiology and treatment of maxillofacial
fractures. J Craniofac
Surg. 2002; 13(6):772-5
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Manson P, Clark N, Robertson B, Crawly W. Comprehensive management of pan facial fractures. J
Craniomaxillofac
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