Frey's syndrome after condylar fracture: case report

Frey's syndrome is the occurrence of hyperesthesia, flushing and warmth or sweating over the distribution of the auriculotemporal nerve and/or greater auricular nerve while eating foods that produce a strong salivary stimulus. Frey's syndrome is also known as auriculotemporal syndrome and gustatory sweating. We present a case of Frey's syndrome after a condylar fracture and its treatment by internal rigid fixation. A review of the literature is provided along with mention of a simple test (Minor's test) that can help in the diagnosis of this syndrome.

Therapeutic effect of TENS on post-IMF trismus and pain

The study set out to investigate the therapeutic effect of Transcutaneous Electrical Nerve Stimulation (TENS) in the alleviation of pain and post-IMF trismus, in patients undergoing jaw exercises to hasten mouth opening after being treated for fractures of the mandible. Two groups of patients, with 10 patients in each group, were used for the study. The groups were the experimental and the control groups. They were all treated for mandibular fractures, and had their jaws immobilized for 6 weeks, immediately after which they were started on jaw exercises. The Inter-incisal distances and number of acceptable wooden spatulae that the jaws could accommodate were noted and recorded. The experimental group was then placed on the TENS therapy for 20 minutes, after which the new inter-incisal distances and the number of acceptable wooden spatulae were recorded. The control group had no TENS therapy; the patients only waited for 20 minutes without any stimulation, before the new inter-incisal distances and the number of acceptable wooden spatulae were measured and recorded. It was observed that the inter-incisal distance and the number of acceptable wooden spatulae significantly increased in patients in the experimental group compared to the control group. It was concluded that TENS could be useful in relieving the pain associated with forced mouth-opening exercises aimed at overcoming trismus caused by muscle spasm, which is associated with prolonged immobilization of the jaws for the treatment of facial fractures.

Comparative assessment of two methods used for interdental immobilization

AIM

This investigation was carried out to compare Dimac wires with arch bars for interdental immobilization.

MATERIAL AND METHODS

The assessment was conducted on 50 patients who had mandibular fractures and in whom intermaxillary fixation was required as a part of the treatment. The time required for applying each method of fixation, the needle-stick injuries that occurred during their application, and the periodontal damage that followed interdental immobilization was investigated.

RESULTS

The mean time required for the application of Dimac wires was significantly less than that required for arch bars. The needle-stick injuries were significantly less with Dimac wires. Patients reported difficulty with oral hygiene with arch bars in place. This was associated with periodontal damage following removal of fixation.

CONCLUSION

Dimac wires is safer to use and less traumatic to the periodontium

Retromandibular approach to the mandibular condyle: a clinical and cadaveric study

This prospective study was carried out to assess the morbidity of the retromandibular approach in the management of condylar fractures. Twenty consecutive patients underwent open reduction and internal fixation of their condylar fractures using this technique. Branches of the facial nerve were encountered in six cases (30%). Temporary weakness of the facial nerve occurred in six patients (30%), but this resolved in all cases within 3 months and there were no cases of permanent nerve injury. Two patients had a temporary deficit of the great auricular nerve and one patient developed a sialocoele that resolved with aspiration. A cadaveric study using 30 facial halves (15 fresh cadavers) was also conducted. Branches of the facial nerve were encountered in 12 dissections (40%). The literature regarding facial nerve morbidity in relation to the management of condylar fractures is reviewed.

Infections associated with locking reconstruction plates: a retrospective review

PURPOSE

In this study, we examined the incidence of infection with the use of a locking reconstruction bone plate/system.

PATIENTS AND METHODS

All patients, treated with a locking reconstruction bone plate/screw system for mandible fractures in the Oral and Maxillofacial Surgery service over a 28-month period at a level I trauma center, were evaluated through a retrospective chart review by independent examiners. The use of a locking reconstruction plate was determined by the attending staff involved in the patient's care. Patient population included single, bilateral, and comminuted fractures. Patient characteristics were noted and include dentate versus edentulous, smoking history, and history of previous infection.

RESULTS

Fifty-six locking bone plates were placed in 42 patients. Eight (19%) of the patients were infected before treatment. A persistent infection remained in 3 of these 8 patients (37.5%). Two patients (5.8%), with 3 fracture sites (6.4%) developed postoperative infection that required further intervention. All 5 of the patients who were infected after surgery were heavy smokers. History of preoperative infection and smoking appear to be significant factors in the etiology of postoperative infection. All postoperative infections resolved successfully with local measures and with no loss of fixation.

CONCLUSION

The use of locking reconstruction plates can facilitate the management of complicated fractures; however, it does not eliminate complications. Postoperative infections are related to numerous factors, including preoperative incidence of infection, smoking, and proper use of the plates.

Treatment of severe mandibular fractures using AO reconstruction plates

PURPOSE

The goal of this study was to retrospectively evaluate the use of 2.4-mm AO titanium reconstruction plates for mandibular fractures.

PATIENTS AND METHODS

We analyzed the clinical and radiologic data of 63 patients with 63 single fractures (53 comminuted, 5 dislocated, and 5 with bone loss) and 2 patients with double fractures. Fracture location was symphysis in 37 patients (56.9%), body in 13 (20%), and angle in 15 (23.1%). We recorded the mechanism of injury, time between injury and surgery, gender and age, temporary maxillomandibular fixation (MMF) and its duration, and surgical approach. Follow-up examinations were performed at 1, 3, 6, and 12 months, at which time we noted the status of healing and any complications.

RESULTS

Fifty patients (77%) had a successful treatment outcome without complications; 13 patients (20%) developed minor complications; and 2 patients (3%) developed nonunion with infection requiring hardware removal and reosteosynthesis with bone graft.

CONCLUSIONS

We found that 2.4-mm AO titanium reconstruction plates can be used to treat severe mandibular fractures with a low rate of major complications (3%) and a high success rate.

Fixation of mandibular fractures with 2.0-mm miniplates: review of 191 cases

PURPOSE

Our goal was to study the use of 2.0-mm miniplates for the fixation of mandibular fractures.

PATIENTS AND METHODS

Records of 191 patients who experienced a total of 280 mandibular fractures that were treated with 2.0-mm miniplates were reviewed. One hundred twelve of those patients, presenting 160 fractures, who attended a late follow-up were also clinically evaluated. Miniplates were used in the same positions described by AO/ASIF. No intermaxillary fixation was used. All patients included had a minimum follow-up of 6 months. Demographic data, procedures, postoperative results, and complications were analyzed.

RESULTS

Mandibular fractures occurred mainly in males (mean age, 30.3 years). Mean follow-up was 21.92 months. The main etiology was motor vehicle accident. The most common fracture was the angle fracture (28.21%). Twenty-two fractures developed infection, for an overall incidence of 7.85%. When only angle fractures are considered, that incidence is increased to 18.98%. Although only 1 patient (0.89%) described inferior alveolar nerve paresthesia, objective testing revealed sensitivity alterations in 31.52% of the patients who had fractures in regions related to the inferior alveolar nerve. Temporary mild deficit of the marginal mandibular branch was observed in 2.56% of the extraoral approaches performed and 2.48% presented with hypertrophic scars. Incidence of occlusal alterations was 4.0%. Facial asymmetry was observed in 2.67% of the patients, whereas malunion incidence was 1.78%. Fibrous union, mostly partial, occurred in 2.38% of the fractures, but only 1 of those presented with mobility (0.59%). Condylar resorption developed in 6.25% of the fixated condylar fractures. Mean mouth opening was 42.08 mm.

CONCLUSION

The overall incidence of complications, including infections, was similar to those described for more rigid methods of fixation.

Effect of maxillomandibular fixation on the incidence of postoperative pulmonary atelectasis

PURPOSE

Our goal was to assess the role of maxillomandibular fixation (MMF) on postoperative atelectasis.

PATIENTS AND METHODS

We examined 64 patients in 2 groups: MMF and non-MMF. Atelectasis was diagnosed by comparing preoperative and postoperative chest radiographs, arterial blood gas analysis, and axial temperatures. Postoperative chest computed tomography scans were also used as the best way to detect atelectasis.

RESULTS

Of the MMF and non-MMF patients, 37.5% and 15.6%, respectively, sustained atelectasis (P <.05). Plate type was the most prevalent (71%). The right lung was more involved (59%). Fever was not a significant finding in atelectatic patients (P >.10). PaO(2) was decreased in some cases of atelectasis, especially in patients with extensive involvement.

CONCLUSION

MMF should be considered as a contributing factor for postoperative pulmonary atelectasis.

Effects of age, amount of advancement, and genioplasty on neurosensory disturbance after a bilateral sagittal split osteotomy

PURPOSE

There are numerous risks for developing neurosensory deficits after a bilateral sagittal split osteotomy (BSSO). The purpose of this study was to evaluate the effects of genioplasty, length of advancement, and age and their interactions in a group of patients undergoing BSSO advancement and followed up for 2 years.

MATERIALS AND METHODS

Patients were examined at multiple time intervals during the 2 years. Measuring in the mental nerve distribution assessed damage. 127 subjects were divided into the following 3 age groups: younger than 24 years, 24 to 35 years, and older than 35 years old. They also were divided into small (< or =7 mm) and large (>7 mm) advancements and genioplasty and no genioplasty. Change in tactile sensitivity from presurgical to the subsequent time periods is reported as a function of these variable and interactions among the variables. Data were analyzed using the Kruskal-Wallis test and the Friedman test, all at an alpha level of 0.05.

RESULTS

Older subjects had greater sensory losses than younger subjects. Patients with a genioplasty had a greater loss of sensation initially. For all subjects, the sensory function of those receiving large and small advancements was not significantly different. Among subjects receiving small advancements there was no significant difference among the 3 age groups. However, among patients receiving advancements greater than 7 mm, older patients did worse. Among patients not receiving genioplasty, there was no significant difference among the 3 age groups. In contrast, older subjects with a genioplasty had significantly greater sensory deficits.

CONCLUSIONS

Age at the time of surgery and addition of a genioplasty increases the risk of a neurosensory injury. Large advancements further increase the risk of injury in older patients.

Treatment methods for fractures of the mandibular angle

Fractures of the mandibular angle are plagued with the highest rate of complication of all mandibular fractures. Over the past 8 years, the following six accepted forms of treatment for these fractures were performed on an indigent inner-city population: closed reduction or intra-oral open reduction and nonrigid fixation; extraoral open reduction and internal fixation with an AO/ASIF reconstruction bone plate; and intraoral open reduction and internal fixation using either two 2.0 mm minidynamic compression plates, two 2.4 mm mandibular dynamic compression plates, two noncompression miniplates, or a single noncompression miniplate. This article reviews the results of those treatment modalities when used for the same patient population at one hospital. Results show that the use of either an extraoral open reduction and internal fixation with the AO/ASIF reconstruction plate or intraoral open reduction and internal fixation using a single miniplate was associated with the fewest complications.

Transverse displacement of the proximal segment after bilateral sagittal osteotomy

PURPOSE

The aim of the present investigation was to evaluate the transverse displacement of the proximal segment and ramus rotation after a bilateral sagittal osteotomy (BSO) with rigid internal fixation (RIF) using bicortical LAG screws.

PATIENTS AND METHODS

We conducted a retrospective review of 37 patients (14 males and 23 females, age range of 14 to 55 years) who underwent a mandibular advancement with BSO and RIF. Posteroanterior and lateral cephalometric radiographs were obtained 1 to 8 weeks before and 1 to 4 weeks after surgery. The transverse displacement and angulation of the proximal segments after surgery were measured on posteroanterior radiographs, using the best-fit method. The amount of mandibular advancement was compared with the amount of transverse displacement of the proximal segments.

RESULTS

In the 1 to 4-week postoperative period after a BSO, 36 of 37 subjects showed an increased transverse intergonion distance (5.6 mm) (P <.0001) and 35 of 37 patients showed an increased transverse interramus width (3.3 mm) (P <.0001). No correlation was found between mandibular advancement and transverse displacement of the proximal segment.

CONCLUSIONS

The study results indicate that transverse displacements of the proximal segments occur with BSO and RIF. The clinical impact on temporomandibular joint symptomatology or surgical relapse with such displacement was not assessed in the study. Future studies that address these issues may help to determine whether there is an association between proximal segment displacement and surgical relapse, temporomandibular dysfunction, or both.

Incidence of complications and problems related to orthognathic surgery: a review of 655 patients

PURPOSE

This retrospective report evaluates the incidence of pre-, intra-, and postoperative complications of orthognathic surgery and their significance to the patient.

PATIENTS AND METHODS

The clinical records and radiographs of 655 patients operated on in Vaasa Central Hospital, Finland during a 13-year period between 1983 and 1996 were examined. The total number of operations was 689. All notes referring to problems or complications from the orthodontic phase to the varying postoperative follow-up times were gathered and analyzed.

RESULTS

The most common complication was a neurosensory deficit in the region innervated by the inferior alveolar nerve; mild in 32% of patients (183 of 574 patients with an osteotomy in the mandible) and disturbing in 3% of patients (18/574). The most serious complication was severe intraoperative bleeding in 1 patient necessitating major blood transfusions and later embolization of the internal maxillary artery. There were no fatal complications. The incidence of other problems was low, and there were very few patient complaints.

CONCLUSIONS

Despite the great variety of severe complications reported in the literature, their frequency seems to be extremely low, and orthognathic surgery treatment can be considered to be a safe procedure.

Plate fixation of extra-oral subcondylar ramus osteotomy for correction of mandibular prognathism: clinical aspects and short term stability

AIM

The present study describes an extra-oral approach for subcondylar oblique ramus osteotomy using stable fixation for setback of the mandible. The aim was to investigate the incidence of neurosensory disturbances of the mandibular nerve, evaluate facial scar appearance, and assess skeletal stability following the procedure.

METHODS

Forty-two consecutive patients with mandibular prognathism were operated upon using the subcondylar oblique ramus osteotomy and plate fixation. The patients were followed up for 6 months following surgery. Intra-operative and postoperative complications, neurosensory function, and facial scar characteristics were recorded. Lateral cephalograms were available immediately before operation, and immediately after operation and 6 months postoperatively. Skeletal stability was based on cephalometric assessment.

RESULTS

Among the 19 patients operated earliest, neurosensory disturbances were recorded in five individuals at the 6 month follow-up. In the subsequent group of 23 patients, no disturbances were reported. All but two patients were not concerned about the facial scar 6 months postoperatively. Mean anterior relapse at the 6 month follow-up was 0.5 mm, representing 9% of the surgical setback.

CONCLUSION

Extra-oral subcondylar oblique ramus osteotomy with plate fixation is a stable procedure with a low incidence of neurosensory disturbances if the osteotomy is placed well behind the mandibular foramen. Facial scar appearance was rarely a matter of concern to the patients.

Effect of partial immobilization on reconstruction of ankylosis of the temporomandibular joint with an autogenous costochondral graft:an experimental study in sheep

The purpose of this study was to show the effect of partial immobilization of a costochondral graft reconstruction of an ankylosed temporomandibular joint (TMJ) in five adult sheep. Ankylosis was induced in all right TMJs. At three months, a graft was inserted and partially immobilized. Three months after the second operation, four sheep were killed by an overdose with pentothal. One sheep was killed at one month because of infection. Functionally, the body weight, which decreases with ankylosis, did not recover after insertion of the graft and the range of jaw movements got worse. Histologically, the grafts were well attached to the mandibular rami in three of four joints. In one joint, the graft showed signs of resorption and a foreign body reaction. We conclude that, if the reconstructed joint is partially immobilized, then there will be a degree of reankylosis. There was also a high failure rate.

Effects of intermaxillary fixation during orthognathic surgery on respiratory function after general anesthesia

I examined the relationship between preoperative breathing route (nasal and/or oral) and respiratory status in 29 patients who underwent orthognathic surgery and intermaxillary fixation (IMF) with general anesthesia and in 14 healthy, adult control volunteers who received IMF without surgery or anesthesia. The tidal volume (VT), minute respiratory volume (MV), respiratory rate, and end-tidal carbon dioxide concentration were measured for both nasal and oral breathing before and after IMF. Pulse oximetry recordings were also taken. There was no significant effect of IMF on any parameter in the volunteers. Fifteen patients engaged in nasal breathing only both before and after surgery with IMF (group pN), and 7 patients had combined nasal and oral breathing before but only nasal breathing after IMF (group pNO). VT and MV decreased (536-357 mL and 7.84-5.40 L, respectively) in group pNO after IMF. These results suggest that assessment of the preoperative breathing status is helpful in predicting postoperative respiratory function after IMF and indicate that patients with preoperative mouth breathing require greater respiratory care after general anesthesia with IMF.

Neurosensory differences after wire and rigid fixation in patients with mandibular advancement

PURPOSE

The purpose of this analysis was to compare the frequency and severity of nerve damage with rigid and wire fixation in patients participating in a prospective, randomized clinical trial.

PATIENTS AND METHODS

One hundred twenty-six patients who required a bilateral sagittal split osteotomy and mandibular advancement were randomly assigned to receive either rigid or wire fixation. Tactile sensation in the mental nerve region bilaterally was determined presurgically and throughout the subsequent 2 years by using monofilament detection and brush stroke direction. Neurosensory levels were compared between the types of fixation over time.

RESULTS

Evaluation with monofilament detection showed no significant difference between types of fixation throughout the 2-year follow-up. However, brush stroke determination showed significantly greater hypesthesia with rigid compared with wire fixation from 8 weeks through 2 years postoperatively.

CONCLUSION

Rigid fixation resulted in more anesthesia in the mental nerve distribution than wire fixation when tested with brush stroke direction. However, increased anesthesia was not present when measured with monofilament determination.

Surgical risk factors for condylar resorption after orthognathic surgery

OBJECTIVE

The purpose of this study was to look for surgical risk factors for condylar resorption after orthognathic surgery.

STUDY DESIGN

Seventeen patients of a group of 452 patients who had undergone orthognathic surgery consecutively and who were in accordance with the inclusion criteria of this study showed postoperative condylar resorption (group I). Preoperative cephalometric characteristics and surgically induced movements of this group were compared with a control group of 17 of 452 patients (group II) in whom postoperative condylar resorption and skeletal relapse did not develop, despite mandibular retrognathism (ANB angle >4 degrees) and high mandibular plane angle (>40 degrees).

RESULTS

The kind of osteosynthesis used was not significantly different between the 2 groups. The amount of surgical advancements and the vertical movements of the jaws were not significantly different between the 2 groups. However, the distal (P =.005) and proximal (P =.007) mandibular segments were rotated significantly further counterclockwise in group I. Surgically induced posterior condylar displacement occurred significantly more frequently (P =.007) in group I.

CONCLUSIONS

Counterclockwise rotation of the distal and proximal mandibular segments and surgically induced posterior condylar displacement seem to be important surgical risk factors for postoperative condylar resorption. Therefore, these movements seem to be contraindicated in patients who are at high risk.

The role of a posteriorly inclined condylar neck in condylar resorption after orthognathic surgery

Recently, it has been reported that a posteriorly inclined condylar neck is associated with condylar resorption following orthognathic surgery, although its role in resorption remains unknown. By cephalometric screening of 240 patients with Angle Class II occlusion 2 years after orthognathic surgery, 11 patients with postoperative condylar resorption were identified. The preoperative posterior inclination of the condylar neck and the surgical risk factors mentioned in the literature, particularly surgically induced counterclockwise rotation of the mandibular proximal segment were evaluated. In all 11 cases, the condylar neck was clearly inclined posteriorly. Counterclockwise rotation of the proximal segment was also observed in all cases, and it amounted to 6.7 degrees (2.5-12 degrees) on average. The contributing role of a posteriorly inclined condylar neck in connection with surgical mandibular movement in postoperative condylar resorption is discussed.

Complication rates associated with different treatments for mandibular fractures

PURPOSE

This study compared the complication rate with different types of mandibular fracture treatment (maxillomandibular fixation, 2-mm miniplates, 2.4-mm AO plates, and 2.7-mm AO plates).

PATIENTS AND METHODS

A total of 245 patients who presented with 386 fractures were retrospectively analyzed. Patient characteristics, type of fracture, severity of fracture, type of treatment used, and occurrence of complications were recorded. Statistical analysis was used to compare complication rates, fracture severity, and type of treatment.

RESULTS

There were no differences in the complication rates for the different types of treatment. There was a significant correlation (P < .05) between fracture severity and the overall complication rate, postoperative infection, and postoperative malocclusion, but there was no significant correlation between these complications and the type of treatment applied.

CONCLUSION

The occurrence of postoperative complications in the treatment of mandibular fractures is fundamentally related to the severity of the fracture rather than to the type of treatment used.