Media item: facial reconstruction after a road crash

Media item: newspaper feature on a survivor of a serious motor vehicle collision and the surgical reconstruction of his face

Publication: Herald Sun

Date published: 6 June 2013

Interviewee: Associate Professor Patrishia Bordbar, specialist oral and maxillofacial surgeon

This page records the media item. The article and its images are the property of the publisher and are not reproduced here.

On the patient

The person featured consented to speak to a newspaper about his own injuries. That consent was to the publisher, for that article. It is not consent to have his case used as promotional material, and this page therefore does not restate his identity, his injuries or his treatment.

Under section 133 of the Health Practitioner Regulation National Law, advertising a regulated health service may not use testimonials about clinical care. A dramatic recovery account presented on a practice website functions as exactly that, however it is framed. Health information about an identified individual is separately protected under the Privacy Act and Victorian health records law.

What follows is general information about the subject.

Maxillofacial trauma

The face is structurally complex and functionally dense: it contains the airway, the eyes, the nerves that supply sensation and movement, and the teeth. Serious facial injury threatens all of them simultaneously.

Causes, in rough order of frequency in Australia: road trauma, assault, falls (particularly in older people), sport, and industrial and agricultural accidents.

The order of priorities

This is not intuitive, and it is worth stating because it explains why facial reconstruction often happens days after the injury rather than immediately.

1. Airway. Facial fractures, swelling, bleeding and displaced tissue can obstruct breathing. This comes before everything.
2. Haemorrhage control. The face has a rich blood supply.
3. Associated injuries — head, cervical spine, chest and abdomen. A significant proportion of severe facial trauma comes with a head injury or a spinal injury, and those are assessed first.
4. Eye assessment. Orbital fractures can trap muscle or threaten vision, and some require urgent intervention.
5. Only then, the facial skeleton and the teeth.

A patient may wait days for reconstruction while swelling settles and other injuries are stabilised. That delay is deliberate and clinically correct.

The reconstruction

Fractures are reduced and fixed with titanium plates and screws, usually through incisions placed inside the mouth or in skin creases so that scars are hidden. Common patterns include mandible fractures, zygomatic (cheekbone) fractures, orbital floor fractures, and mid-face fractures of the maxilla. What oral and maxillofacial surgery involves is set out separately.

Restoring the bite is the reference point. In facial reconstruction the teeth are the most precise landmark available — they fit together in one specific way, and re-establishing that occlusion is how a surgeon knows the jaw has been returned to its correct position. This is precisely why oral and maxillofacial surgery is a dental specialty as well as a surgical one.

Virtual planning and patient-specific implants are now widely used: the injury is modelled from a CT scan, the reconstruction planned on screen, and cutting guides or custom plates manufactured to match. Where one side is intact, it can be mirrored to reconstruct the other. Orthognathic surgery uses the same planning tools for a different purpose.

Recovery, honestly

• Swelling is substantial for the first weeks.
• A soft or liquid diet for around six weeks is common, and some fractures require the jaws to be temporarily fixed together.
• Altered or absent sensation in the lip, chin, cheek or gum is common after jaw and mid-face fractures. It usually improves over months and is sometimes permanent.
• Restricted mouth opening frequently needs a course of exercises, and jaw pain afterwards has more than one possible source.
• Further surgery is often required — for plate removal, scar revision, or secondary correction where healing has not produced the intended position. What to expect during recovery applies to the smaller procedures too.
• The psychological dimension is significant and under-treated. Facial injury affects identity in a way a limb fracture does not, and post-traumatic stress after road trauma is common — as is anxiety about returning to a dental chair.

The dental part, which takes years

Facial reconstruction gets the attention; rebuilding the dentition takes far longer.

1. Immediate care — replanting avulsed teeth, splinting loosened ones, managing fractures.
2. Monitoring over months. Traumatised teeth may recover, may die, or may undergo root resorption. Treating too early can mean treating a tooth that would have survived; too late means infection.
3. Root canal treatment where the pulp has died, sometimes with internal bleaching for a darkened tooth.
4. Restoration — composite, veneers, crowns.
5. Replacement of lost teeth — bridge, denture, or implant. In a young patient, implants generally wait until growth is complete, which can mean years of interim solutions.
6. Orthodontics, where teeth or jaw segments have been displaced.

A tooth that darkens weeks or months after an impact needs assessment, not observation. So does one that becomes tender to bite on.

Paying for it

• In Victoria, the Transport Accident Commission (TAC) covers treatment for injuries from transport accidents, including dental and maxillofacial rehabilitation. This is a no-fault scheme, and claims should be lodged promptly.
• WorkSafe for work-related injury.
• Victims of Crime Assistance where the injury resulted from a violent crime — it can cover dental expenses, generally requires a police report, and has time limits.
• Public hospital care for the acute surgical phase.

These schemes are under-used for the long dental tail of an injury, which can continue for a decade. If a claim is open, ask specifically whether ongoing restorative work is covered, and keep the written itemised quotes.

What an oral and maxillofacial surgeon is

The longest of the Australian dental specialty pathways: a dental degree, general practice experience, RACDS primary examinations, a medical degree, four years of accredited hospital surgical training, and fellowship examinations — commonly fifteen years or more. Practitioners hold specialist registration with the Dental Board of Australia, and the title is protected. Why a case goes to a specialist is explained separately.

Common questions

An adult tooth has just been knocked completely out. What do I do in the next ten minutes?

This is the one dental situation where minutes decide the outcome. The International Association of Dental Traumatology calls an avulsed permanent tooth “one of the few real emergency situations in dentistry”.

Put it back, now, at the scene. “Immediate replantation of the avulsed tooth is the best treatment at the place of the accident.” Hold it by the crown, not the root. If it is dirty, Better Health Victoria advises rinsing it briefly in milk or saline, or in the person's own saliva — avoid water if there is any alternative, though a brief water rinse beats pushing dirt into the socket.

If you cannot replant it, there is an order of storage media. In the IADT's words: “in descending order of preference, milk, HBSS, saliva (after spitting into a glass for instance), or saline are suitable and convenient storage mediums. Although water is a poor medium, it is better than leaving the tooth to air-dry.” Root-surface dehydration “starts to happen in a matter of a few minutes”.

The clock that matters is dry time, not total time. “After an extra-alveolar dry time of 30 minutes, most PDL cells are non-viable”; beyond 60 minutes dry, they are “likely to be non-viable” regardless of a later storage medium. Tell whoever treats you how long the tooth was dry.

One exception, and it is absolute: a baby tooth is never put back. Replanting a primary tooth can damage the permanent tooth developing beneath it.

How often does a tooth come out completely, and is putting it back always right?

Less often than the fear suggests: the IADT puts avulsion of permanent teeth at “0.5%–16% of all dental injuries”. The width of that range reflects genuinely different populations, not uncertainty you can resolve.

Replantation is “in most situations, the treatment of choice”, but not always. The guidelines name where it is not indicated — “severe caries or periodontal disease, an uncooperative patient, severe cognitive impairment requiring sedation, severe medical conditions such as immunosuppression, and severe cardiac conditions”.

And they are candid that replanting is not a cure: “some of the replanted teeth have low probability of long-term survival and may be lost or condemned to extraction at a later stage. However, not replanting a tooth is an irreversible decision and therefore saving it should be attempted.” Replanting buys time even when it does not buy a permanent result — which is the reasoning to hold on to at the roadside.

Does a mouthguard actually prevent this, and does the type matter?

The Australian Dental Association's policy on oral injuries is unusually direct about the hierarchy. “The most effective protection against oral damage is a custom fitted mouthguard, where precision fit and quality materials offer maximum comfort & injury prevention.”

On the shop-bought alternative it is fair rather than dismissive: “Over-the-counter mouthguards provide better protection than no mouthguard, however their protection varies depending on the design, comfort, adaptation and thickness of the final product” — adding that “quality control of at-home custom adaptation is not achievable.” So the boil-and-bite is worth wearing; it is simply not equivalent.

Two details people miss. The policy names the sports where a mouthguard “would be impractical or not warranted due to low risk of injury, including swimming, athletics, aerobics, and rowing” — a short list, and most field and court sports are not on it. And “oral piercing jewellery may also increase the risk and degree of oral injury.” Sports mouthguards covers fitting.

After a facial injury, why so many X-rays?

Because “not all signs of injury will be evident clinically” — root fractures, alveolar bone fractures and the position of developing permanent teeth are radiographic findings, and European paediatric guidance names periapical radiographs as “the first choice for the radiological examination of dental trauma”. In one study of 4,455 intraoral radiographs in children and adolescents, trauma was the most frequent indication, at 28.7% — ahead of decay.

The same study calculated an average effective dose of 0.77 µSv for dental and bitewing radiographs; the IAEA describes intraoral doses as “usually less than one day of natural background radiation”. Cone beam CT is the different case — its doses “may be tens or even hundreds of µSv of effective dose higher than conventional radiographic techniques”, which is why it should be a considered decision rather than routine. The test to apply, in the guidance's own words: “a justified radiograph should make a substantial contribution to distinguishing between treatment options”. How safe are dental X-rays? has the detail.

Related reading

• Dr Ricky Kumar, Specialist Oral and Maxillofacial Surgeon and the rest of Specialist Care
• Australian hospital becomes a centre of excellence in facial prosthetics
• What should I do when a tooth is knocked out? and what is considered a dental emergency?
• Complex dentistry
• More coverage in Our Media

Practical details

A/Prof Bordbar's specialist registration — DEN0001010517 — can be verified on the AHPRA public register at ahpra.gov.au.

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000. Phone 13 13 96, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment.

Acute facial trauma is a hospital emergency. Call 000 or go to an emergency department.

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