Complications in patients with facial bone fractures before and after conservative and surgical treatment, their comparison and correlation with different factors

OBJECTIVE

This study aims to determine the occurrence of complications before and after the treatment of facial fractures, as well as the impact of the factors on the treatment results and evaluation of their relationships.

PATIENTS AND METHODS

This is a prospective case-control study comprising 90 patients aged between 18 and 65 with facial fractures. Depending on the treatment method, patients were divided into three groups: those treated surgically using a transcutaneous approach, those treated surgically using a transmucosal approach, and those treated conservatively (control group). Following complications before and after treatment were compared: malocclusions, paresthesias, facial asymmetry, diplopia, and limited mouth opening. The follow-up period after the treatment of choice was six months.

RESULTS

There was a significant reduction in complications after treatment: malocclusion, paresthesia, facial asymmetry, and limited mouth opening. Regarding the transcutaneous approach, there is a substantial reduction in the number of complications after treatment, such as malocclusions (p=0.008), paresthesias (p=0.004), and facial asymmetries (p<0.001). Similar results were obtained for the transmucosal approach. Pain intensity positively correlated with preoperative complications: malocclusion, paresthesias, and facial asymmetry. The range of mouth opening had a negative interdependence with malocclusion before and after treatment with infection, fractura male sanata, malocclusion, paresthesias, postoperative level of mouth opening, and damage to the facial nerve.

CONCLUSIONS

There is no difference in the reduction of preoperative and postoperative complications related to surgery when an incision is made through the skin or mucosa. Malocclusions, paresthesias, and facial asymmetry are reduced through surgical methods.

Anatomical position of the mandibular condyle after open versus closed treatment of unilateral fractures: A three-dimensional analysis

This study aimed to compare open and closed treatment for unilateral mandibular condyle neck and base fractures by final three-dimensional (3D) condylar position at 6 months follow-up. 3D position was associated with mandibular functioning and pain. A total of 21 patients received open (n = 11) or closed (n = 10) treatment. 3D positions were assessed on cone-beam computed tomography scans. Volume differences, root mean square, translations, and rotations were obtained related to the pursued anatomical position and compared between treatment groups by the Mann-Whitney U test. The 3D position parameters were associated with the maximum interincisal opening (MIO), mixing ability test (MAT), Mandibular Function Impairment Questionnaire (MFIQ), and pain based on Spearman correlation coefficients (rs). Translation in the medial-lateral direction was smaller after open treatment (P = 0.014). 3D position was not associated with the MAT; however, worse position was associated with a smaller MIO. A larger pitch rotation was associated with a worse MFIQ (rs = 0.499, P = 0.025). Volume reduction of the affected condyle was associated with more pain (rs = -0.503, P = 0.020). In conclusion, after unilateral condylar fractures, worse 3D position is associated with a smaller mouth opening and worse patient-reported outcomes. This is independent of the chosen treatment, despite a better anatomical reduction after open treatment.

Endoscopic-assisted intraoral approach for mandibular condyle fracture management: A systematic review and meta-analysis

OBJECTIVE

Surgical innovation led to an endoscopic-assisted intraoral approach for managing condyle fractures. The purpose of this systematic review is to purview the role of the endoscope and determine the range of information, summarizing the evidence for the benefit of surgeons on an endoscopic-assisted intraoral approach.

STUDY DESIGN

A literature search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane Library databases for studies mentioning the endoscopic intraoral approach for managing mandibular condylar fractures. Outcomes include the role of the endoscope, challenges, adjunct armamentarium, duration, and complications associated with the transoral and transbuccal approach for screw fixation. The meta-analysis was conducted with prevalence estimates and standardized means using STATA.

RESULTS

Thirty-nine studies were included. A 30° angulated, 4-mm-thick endoscope was the most commonly used endoscope. Two mini plates were most commonly used for fixation. Facial nerve weakness was higher in the transbuccal approach (1.24%) than in the transoral approach (0.8%). Pooled analysis (6 studies) showed that the duration of the surgical procedure was less in the transoral approach compared with the transbuccal approach for screw fixation. The bailout was 1.49%.

CONCLUSIONS

The endoscopic-assisted intraoral approach is reliable for condylar fracture management. The transoral and transbuccal approaches can be used for screw fixation with comparable outcomes.

A Case Report of Oral Bisphosphonate Treatment for Osteoporosis Leading to Atypical Femoral Fracture and Pathologic Mandibular Fracture

BACKGROUND Bisphosphonates inhibit bone resorption in patients with postmenopausal osteoporosis and reduce osteoporotic fracture incidence. Medication-related osteonecrosis of the jaws (MRONJ) and atypical femoral fractures (AFF) are both rare but serious adverse effects of anti-resorptive drugs (ARD) such as bisphosphonates. The most advanced form of MRONJ is termed stage 3 and can lead to severe local sequelae like pathologic mandibular fractures (PMF). This study reports a case of MRONJ-related PMF and AFF with osteomyelitis secondary to bisphosphonate treatment for osteoporosis. CASE REPORT A 63-year-old white woman was diagnosed with PMF related to MRONJ stage 3 during treatment of an AFF with osteomyelitis. She had been treated for postmenopausal osteoporosis with 70 mg of alendronate weekly for 2 years. The PMF was treated by stable internal fixation combined with debridement and sequestrectomy, but further debridement was required and 2 mandibular implants were then removed. Postoperative recovery was uneventful and the mandibular infection was controlled after the second surgery. Three weeks later, she was discharged from the hospital, instructed to discontinue the use of alendronate, and referred for 30 sessions of hyperbaric oxygen therapy. At the 3-year follow-up, the PMF was completely healed without signs of mandibular infection or bone exposure. CONCLUSIONS This report raises awareness of both MRONJ and AFF as possible adverse effects of short-term bisphosphonate therapy for postmenopausal osteoporosis, and highlights the importance of dental and orthopedic follow-ups. It is crucial to emphasize the need for early diagnosis and treatment to prevent MRONJ progression to PMF.

Z-shaped Miniplates vs Conventional Miniplates for Fixation of Mandibular Parasymphyseal Fractures

AIM

The aim of this study was to evaluate a clinically and radiographically Z-shaped miniplate for the fixation of the parasymphyseal fractures.

PATIENTS AND METHODS

Twenty patients (10 patients in each group) who had parasymphseal mandibular fractures were randomly selected for this study. In this study, open reduction and internal fixation were performed for mandibular parasymphyseal region fractures using two miniplates as group I, and open reduction and internal fixation were performed for mandibular parasymphyseal region fractures using a newly designed Z-shaped miniplate as group II. Clinical and radiographic evaluations were made. Each patient was evaluated: (1) clinically evaluated preoperatively and postoperatively for operating time, ease of placement of the miniplate, and occlusion and (2) radiological: postoperative reduction of fracture was evaluated radiologically at 5-day, 1-month, 2-month, and 3-month intervals with orthopantomogram, and lingual splaying was evaluated by cone-beam computed tomography (CBCT) immediately postoperatively and at an interval of 3 months. The collected data were subjected to statistical analysis. Data analysis was performed by SPSS software, version 25 (SPSS Inc., PASW statistics for Windows version 25). Chicago: SPSS Inc.

RESULTS

There was a statistically significant difference (p < 0.001) between the mean intraoperative time. This indicates that group I had a longer time for fracture fixation than group II. Group I had a longer time elapsed for plate adaptation and definitive fixation than group II. Occlusion and reduction stability in both groups were similar. There was a statistically significant difference in postoperative lingual display control after 5 days and 3 months between the studied groups. This indicates that lingual display control in group II is better than in group I.

CONCLUSION

The Z-shaped miniplate is effective and provides three-dimensional stability for the fixation of parasymphyseal fractures, ease of use, easily adapted in cases of fractures near the mental nerve reduced operative time, and better control of lingual splaying than conventional miniplates.

CLINICAL SIGNIFICANCE

The newly designed Z-shaped miniplate is a valuable option for fixation parasymphysis fractures that need open reduction and internal fixation instead of using conventional miniplates, which are less successful in controlling lingual splaying.

Analysis of postoperative complications related to cannabis and tobacco usage in patients undergoing mandible facial fracture surgeries

BACKGROUND

Cannabis is the third most used controlled substance in the world. Despite its widespread use, minimal research investigates cannabis usage in patients undergoing facial fracture surgeries. This study aimed to evaluate patterns of postoperative complications related to cannabis and tobacco usage after mandible fracture surgeries.

MATERIALS AND METHODS

PearlDiver™, a commercially available healthcare database, was used to identify patients endorsing the use of cannabis, tobacco, or both who underwent mandible fracture surgeries for cross-sectional analysis. The study population was categorized into groups using the Classification of Diseases, 9th revision (ICD-9), ICD-10, and Current Procedural Terminology (CPT) codes. A chi-square analysis was performed to assess the influence of cannabis and tobacco use on postoperative complications.

RESULTS

A total of 8288 patients met the inclusion criteria, with 72 patients with cannabis-only usage, 914 patients with cannabis and tobacco usage, 3236 patients with tobacco-only usage, and 4066 in the control group. For patients using only cannabis, there was not an increased risk of developing postoperative complications compared with the control population. Patients with concurrent cannabis and tobacco usage and those with tobacco-only usage had an increased risk of surgical site infection, facial nonunion, facial abscess, debridement, and malocclusion after surgical repair of mandibular facial fracture.

CONCLUSION

Patients with tobacco-only as well as cannabis and tobacco usage had an increased risk of all postoperative complications, except malocclusion, compared with cannabis-only. Based on the results of this study, it is recommended that healthcare providers consider a patient's history of tobacco use when planning and performing surgical treatment for traumatic mandible fractures.

Retention of teeth in the fracture gaps of the mandible: a retrospective analysis

OBJECTIVES

Since the introduction of miniplate osteosynthesis and the use of prophylactic antibiotics, the complication rate related to the teeth in the fracture gap has significantly decreased. Currently, there are still no established guidelines for the management of such teeth in mandibular fracture lines. However, the long-term viability of these teeth within the fracture gap remains uncertain. Therefore, this study aimed to assess the survival rate of teeth located within the mandibular fracture line and evaluate related follow-up treatments over a minimum period of one year.

MATERIALS AND METHODS

This retrospective study examined 184 patients who underwent surgical treatment for mandibular fractures between January 2018 and December 2021. A total of 189 teeth located in the fracture line were analyzed. Clinical and radiological parameters were collected, including patient age and gender, fracture etiology and location, intraoperative tooth treatment, as well as complications related to both the fracture and the affected teeth in long term.

RESULTS

Most of the examined teeth remained uneventful, with postoperative tooth-related complications seen in 14 (7.4%) teeth. The most common complications were symptomatic apical periodontitis (n = 9, 4.8%) and increased tooth mobility (n = 3, 1.5%). A correlation was found between complications and trauma-related tooth luxation (p = 0.002, OR = 15.2), as well as prior teeth connected to retainers or orthodontic appliances (p = 0.001, OR = 10.32).

CONCLUSION

Tooth-related complications are rare when intact teeth are retained within the fracture gap. Therefore, unless there is a definitive intraoperative indication for extraction, it is recommended to preserve the teeth in the fracture line.

CLINICAL RELEVANCE

Intact teeth in the fracture line of the mandible should not be primarily extracted.

The Use of Combined Microplate And Miniplate in the Fixation of the Mandibular Fractures (A Randomized Clinical Trial)

The study group patients have been treated with 1.6 microplates at the superior border and 2.0 miniplate at the inferior border to evaluate its efficacy in the fixation of symphyseal and parasymphyseal fractures using this technique. The control patients were treated with two 2.0 plates. The stability was assessed using computed tomography immediately performed postoperatively and after 6 months. Assessment of the change in the intercanine distance using the Student T test was statistically Non Significant ( P value 0.34). The change of intercanine distance in the study was 0.04 ± 0.05 mm, compared with that of the control, which was 0.01 ± 0.03 mm. Assessment of change in intermental foramina distance was statistically NS ( P value = 0.06). The average difference in intermental foramina distance in the study was 0.04 ± 0.05 mm, compared with the control, which was 0.002 ± 0.004 mm. Based on the findings of the current study, the authors recommend the use of microplates combined with miniplates in the correction of both symphyseal and parasymphyseal fractures successfully.

Treatment for Adult Mandibular Condylar Process Fractures: A Network Meta-Analysis of Randomized Clinical Trials

PURPOSE

Using network meta-analyses (NMA) has become increasingly valuable as it enables the comparison of interventions that have not been directly compared in a clinical trial. To date, there has not been a NMA of randomized clinical trials (RCT) that compares all types of treatments for mandibular condylar process fractures (MCPFs). The aim of this NMA was to compare and rank all the available methods used in the treatment of MCPFs.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search was conducted in 3 major databases up to January 2023 to retrieve RCTs that compared various closed and open treatment methods for MCPFs. The predictor variable is treatment techniques: arch bars (ABs) + wire maxillomandibular fixation (MMF), rigid MMF with intermaxillary fixation screws, AB + functional therapy with elastic guidance (AB functional treatment), AB rigid MMF/functional treatment, single miniplate, double miniplate, lambda miniplate, rhomboid plate, and trapezoidal miniplate. Postoperative complications were the outcome variables and included occlusion, mobility, and pain, among other things. Risk ratio (RR) and standardized mean difference were calculated. Version 2 of the Cochrane risk-of-bias tool and Grading of Recommendations, Assessment, Development, and Evaluations system were used to determine the certainty of the results.

RESULTS

The NMA included a total of 10,259 patients from 29 RCTs. At ≤6 months, the NMA revealed that the use of 2-miniplates significantly reduced malocclusion compared to rigid MMF (RR = 2.93; confidence interval [CI]: 1.79 to 4.81; very low quality) and functional treatment (RR = 2.36; CI: 1.07 to 5.23; low quality).Further, at ≥6 months, 2-miniplates resulted in significantly lower malocclusion compared to rigid MMF with functional treatment (RR = 3.67; CI: 1.93 to 6.99; very low quality).Trapezoidal plate and AB functional treatment were ranked as the best options in 3-dimensional (3D) plates and closed groups, respectively.3D-miniplates (very low-quality evidence) were ranked as the most effective treatment for reducing postoperative malocclusion and improving mandibular functions after MCPFs, followed closely by double miniplates (moderate quality evidence).

CONCLUSIONS

This NMA found no substantial difference in functional outcomes between using 2-miniplates versus 3D-miniplates to treat MCPFs (low evidence).However, 2-miniplates led to better outcomes than closed treatment (moderate evidence).Additionally, 3D-miniplates produced better outcomes for lateral excursions, protrusive movements, and occlusion than closed treatment at ≤6 months (very low evidence).

Use of chin sling for conservative treatment of mandibular fracture in a guinea pig (Cavia porcellus)

OBJECTIVE

To describe a treatment for a mandibular fracture in a guinea pig (Cavia porcellus).

ANIMAL

A 6-month-old sexually intact male guinea pig referred for a 24-hour history of hyporexia.

CLINICAL PRESENTATION, PROGRESSION, AND PROCEDURES

Physical examination showed lateral displacement of the incisors and inflammation and crepitation during mandible lateralization. Imaging tests revealed a minimally displaced complete oblique fracture of the left mandible with fracture of the left mandibular first premolar tooth and incisor tooth.

TREATMENT AND OUTCOME

Conservative treatment was established by placing a chin sling (CS) to immobilize the jaw and a nasogastric tube for nutritional support. Imaging tests repeated 3 weeks later showed initial callus formation, and the conservative treatment was discontinued. Follow-up examinations showed appetite and progressive weight gain. Five months later, the clinical crown of the left mandibular incisor was absent and a resorptive lesion on the left mandibular first premolar tooth was detected. Complete ossification of the fracture without premolar and moler teeth elongation was observed on control imaging tests. Ten months after initial examination, the patient was reportedly healthy with no signs of pain or dental disease.

CLINICAL RELEVANCE

Jaw fracture treatments in guinea pigs are poorly described in the literature. Surgical treatment can be challenging in this species due to its skull and dental anatomy. Although CS was originally employed to increase the congruency of premolar and molar teeth after coronal reduction, this device yielded satisfactory results as a noninvasive, inexpensive treatment of a mandibular fracture in this guinea pig. Alopecia on the back of the head was the only undesired adverse effect associated with the CS.

Biomechanical influence of plate configurations on mandible subcondylar fracture fixation: a finite element study

Mandible subcondylar fractures have very high complication rate, yet there is no consensus on suitable plate design for optimal patient outcomes. Our study is aimed at comparing single mini, trapezoid, lambda, strut and double mini plates. A finite-element (FE) model of intact mandible was developed based on healthy CT-scan data, which was further virtually osteotomized and fixated with plates. The cortical and cancellous bones were assigned region-specific orthotropic and heterogenous isotropic material properties respectively. The models were subjected to six load cases representing the mastication cycle. Under opposite lateralities, the tensile and compressive mandibular strain distributions were found as the opposite, with tensile strains at the posterior border under ipsilateral molar clenching (RMOL) resulting in lesser mandibular strain in reconstructed mandible with single mini plate under RMOL but highest mandibular strain under the contralateral molar clenching (LMOL). Owing to the reduced mandibular strains under LMOL than RMOL, the contralateral chewing is preferred during the immediate post-surgery period for patients. Under LMOL, the peak von Mises stresses in the plate decreased with increase in the number of screws. Furthermore, the presence of two arms in double mini and trapezoid plates seems beneficial to neutralise the tensile and compressive strains across load cases.

Biomechanical Comparison of Titanium and Poly- L -Lactic Acid Trapezoidal Plates Applied in a Subcondylar Fracture Model

BACKGROUND/AIM

Different types of plates are used in clinical practice for the management of subcondylar fractures. This study aimed to compare the performance of poly- L -lactic acid (PLLA) and titanium trapezoidal plates in the fixation of subcondylar mandibular fractures using finite element analysis.

METHODS

Titanium and PLLA trapezoidal plates and screws were placed on the virtual model obtained from computed tomography images of a patient with a subcondylar fracture to perform finite element analysis. The analysis included maximum tension distribution, maximum principal strain, displacement, and deformation of the bone, plates, and screws.

RESULTS

The maximum tension distribution and maximum principal stress were found to be significantly higher on the titanium plate than on the PLLA plate and screws. Almost no difference was found between the trapezoidal and PLLA plates regarding the displacement of the fracture fragments at the fracture line. No difference was recorded regarding the displacement of the PLLA and titanium screws. The values of maximal principal strain between the PLLA and titanium materials showed no significant difference.

CONCLUSIONS

The trapezoidal PLLA plates can be an alternative to trapezoidal titanium plates due to their functional stability and rigidity.

A rare case of bilateral pseudoaneurysm secondary to mandibular condyle fracture-a case report with review of literature

This paper aims to present a rare case report of bilateral pseudoaneurysm secondary to condylar fracture and its management with a brief review of literature. A patient of age 19 years with alleged history of road traffic accident presented 6 weeks lately to our department with slow growing swelling in right preauricular area. History revealed bilateral condylar fracture with right parasymphysis fracture of mandible for which patient underwent maxillomandibular fixation for 4 weeks. The diffuse swelling in preauricular region showed positive signs of pulsation and audible bruit. Ultrasonography and contrast-enhanced computed tomography suggested the bilateral presence of vascular anamoly from the terminal branches of external carotid artery. Diagnostic angiography confirmed presence of pseudoaneurysm at the bifurcation of the internal maxillary artery and superficial temporal artery (STA) on right side whereas on the left side it was at proximal STA. Bilateral endovascular coil and gel foam embolization was done and thrombosis was confirmed with high frequency ultrasound on fourth postintervention day. The swelling completely resolved in a period of 1 month with no evidence of recurrence in the following 2-year follow-up period. Routine investigation revealed presence of pseudoaneurysm on left side which was completely without any clinical signs as repoterd by many cases of condylar fracture in the literature review. Pseudoaneurysm may remain silent and are exposed intraoperatively with massive bleeding which causes significant morbidity. Hence, prompt diagnosis and management is essential to avoid unexpected complication perioperatively.

Control of Mandibular Width With 3D Printed Occlusal Splint in Children With Multiple Mandibular Fractures

BACKGROUND

The fracture of mandibular symphysis combined with bilateral condylar fractures often leads to changes in the width of the mandible, which significantly widens the face of the child. Therefore, it is necessary to reposition the mandible through accurate adduction.

METHODS

To ensure that the mandible can be accurately repositioned, a 3D printed occlusal splint was used. Bilateral maxillomandibular fixation screws were implanted. The 3D printed occlusal splint was located on the maxillary dentition and fixed to the maxillomandibular fixation screws with wire loops. The reference basis for adduction is to make the mandibular dentition located in the occlusal splint. The absorbable plate was contoured according to the restored model and fixed at the fracture site. The 3D printed occlusal splint was retained in the maxillary dentition for two months.

RESULTS AND DISCUSSION

Postoperative computed tomography showed that the mandible had been adducted according to the preoperative design. Two months of follow-up showed that the child's facial development, mouth opening type, occlusion, and range of motion were good. It is especially suitable for children with mandibular symphyseal fractures accompanied by bilateral condylar fractures.

Parameter optimization in a finite element mandibular fracture fixation model using the design of experiments approach

Only a few mandibular bone finite element (FE) models have been validated in literature, making it difficult to assess the credibility of the models. In a comparative study between FE models and biomechanical experiments using a synthetic polyamide 12 (PA12) mandible model, we investigate how material properties and boundary conditions affect the FE model's accuracy using the design of experiments approach. Multiple FE parameters, such as contact definitions and the materials' elastic and plastic deformation characteristics, were systematically analyzed for an intact mandibular model and transferred to the fracture fixation model. In a second step, the contact definitions for the titanium screw and implant (S-I), implant and PA12 mandible (I-M), and interfragmentary (IF) PA12 segments were optimized. Comparing simulated deformations (from 0 to -5 mm) and reaction forces (from 10 to 1'415 N) with experimental results showed a strong sensitivity to FE mechanical properties and contact definitions. The results suggest that using the bonded definition for the screw-implant contact of the fracture plate is ineffective. The contact friction parameter set with the highest agreement was identified: titanium screw and implant μ = 0.2, implant and PA12 mandible μ = 0.2, interfragmentary PA12 mandible μ = 0.1. The simulated reaction force (RMSE = 26.60 N) and surface displacement data (RMSE = 0.19 mm) of the FE analysis showed a strong agreement with the experimental biomechanical data. The results were generated through parameter optimization which means that our findings need to be validated in the event of a new dataset with deviating anatomy. Conclusively, the predictive capability of the FE model can be improved by FE model calibration through experimental testing. Validated preoperative quasi-static FE analysis could allow engineers and surgeons to accurately estimate how the implant's choice and placement suit the patient's biomechanical needs.

Craniomaxillofacial Trauma: The Past, Present and the Future

Reconstruction of facial trauma has seen a significant evolutionary leap in the last 100 years. The current surgical management of facial fractures was made possible by the efforts and creativity of pioneer surgeons, advances in anatomic understanding, and the continued development of biomaterials and imaging technologies. Virtual surgical planning (VSP) and 3-dimensional printing (3DP) are being incorporated into the management of acute facial trauma. The integration of this technology at the point of care is rapidly expanding globally. This article reviews the history of the management of craniomaxillofacial trauma, current practices, and future directions. The use of VSP and 3DP in facial trauma care is highlighted with a description of EPPOCRATIS, a rapid point-of-care process incorporating VSP and 3DP at the trauma center.

Remodelling of mandibular condylar head after fixation of fractures with ultrasound activated resorbable pins: A retrospective case series

The aim of this study was to assess whether the resorption of poly-lactic acid pins, used for condylar head fracture fixation, adversely affect remodelling of the condylar head. A retrospective review of patients was performed that underwent ORIF of CHF with ultrasound activated resorbable poly-lactic acid pins and had CT/CBCT scans of the condyle at least 18 months after surgery, at which point the fixation material was expected to be resorbed. We reviewed the size, shape and position of the condylar head and compared this to the normal side and compared this to the results of conservative management and ORIF with titanium screws in the literature. Most patients had condylar heads normally positioned and shaped, with minimal bone changes. The position of the condyle in the fossa, its shape and bone changes compare favourably with previous studies on CHF managed conservatively or with titanium screw fixation. There was no radiographic evidence of the pins after 18 months. In conclusion, ultrasound activated resorbable pins can provide suitable fixation for ORIF of condylar head fractures, avoiding the need for screw removal, and there was no evidence that the resorption process adversely affected the remodelling of the condylar head.

Comparing the Efficacy of Postoperative Antibiotic Regimens in the Treatment of Maxillofacial Fractures: A Prospective Study

AIM

The present study was designed to investigate the difference in the effectiveness of a 3 day postoperative course and a single perioperative dose of antibiotics on the incidence of postoperative infection in the management of maxillofacial trauma patients.

MATERIALS AND METHODS

About 183 maxillofacial trauma patients requiring open reduction and internal fixation (ORIF) under general anesthesia were divided based on the type of fracture sustained, i.e., mandibular fractures, Le Fort fractures, and zygomaticomaxillary complex fractures. Patients from each fracture type were randomized into two groups, A and B. All patients were administered amoxicillin/clavulanate 1.2 grams intravenously 8 hours from the time of admission till the patient was taken up for surgery. Once the patients were taken up for surgery, a perioperative dose was administered. No antibiotics beyond this point were given to patients in Group A. Patients in Group B were administered the same antibiotic for 3 postoperative days additionally. Outcomes in terms of purulent discharge from the surgical site, an abscess or any other sign of infection, and wound dehiscence requiring reopening of the surgical site were considered. Patients were reviewed at 1 week, 2 weeks, 1 month, 2 months, and 3 months.

RESULTS

No statistically significant difference was found between the two groups across all three fracture types in terms of postoperative outcomes. However, increased numbers of complications were noted in the patients treated with an intra-oral approach in each fracture type irrespective of group. All complications were managed with local measures.

CONCLUSION

A single perioperative dose of antibiotics is effective in minimizing postoperative complications following ORIF of maxillofacial fractures and there is no significant benefit in prolonging the course of antibiotics postoperatively with the need for further studies to be conducted considering comminuted, complex fractures and old fractures.

CLINICAL SIGNIFICANCE

In maxillofacial trauma, fractures frequently communicate with contaminated indigenous flora on the skin surface, oral cavities, or sinus cavities. Surgery is frequently performed using an approach across a contaminated area, even in closed fractures. Postoperative infections can be significantly decreased by using antibiotics in surgical procedures to treat facial fractures.

Preoperative Prophylactic Antibiotics in Mandibular Fractures and Surgical Site Infection

BACKGROUND

Compared with other facial fractures, mandibular fractures have the highest rate of postsurgical site infection. There is strong evidence to suggest that postoperative antibiotics do not reduce rates of surgical site infections (SSIs) regardless of duration. However, there are conflicting data in the literature regarding the role of prophylactic preoperative antibiotics in reducing rates of SSIs. This study reviews the rate of infections in patients who underwent mandibular fracture repair who received a course of preoperative prophylactic antibiotics compared with those who received no or 1 dose of perioperative antibiotics.

METHODS

Adult patients who underwent mandibular fracture repair at Prisma Health Richland between 2014 and 2019 were included in the study. A retrospective cohort review was conducted to determine the rate of SSI, comparing 2 groups of patients who underwent mandibular fracture repair. Patients who received more than 1 dose of scheduled antibiotics before surgery were compared with those who did not receive any antibiotic treatment before surgery or received only a single dose of antibiotics within 1 hour of incision time (perioperative antibiotics). The primary outcome was the rate of SSI between the 2 groups of patients.

RESULTS

There were 183 patients who received more than 1 dose of scheduled antibiotics before surgery and 35 patients who received a single dose of perioperative antibiotics or did not receive any antibiotics. The rate of SSI was not significantly different in the preoperative prophylactic antibiotics group (29.3%) compared with the patients who received a single perioperative dose or no antibiotics (25.0%).

CONCLUSION

Extended regimens of preoperative prophylactic antibiotics beyond a single dose at time of surgery do not reduce SSIs after surgical repair in mandibular fractures.

Biodegradable Plates for Mandibular Fracture Fixation in Young Children

Mandibular fractures are rare in children and normally result from high-impact trauma. Clinical protocols have evolved in recent years, especially after the introduction of rigid internal fixation methods and the development of novel resorbable materials. The purpose of this report is to present the case of a three-year-old toddler who fell from a bunk bed at home, resulting in a unilateral fracture of the mandibular parasymphysis and a joint fracture on the left side. The patient was treated under general anesthesia with rigid internal fixation with biodegradable plates and screws. Pediatric patients can benefit from resorbable materials, especially their faster mobilization and avoidance of secondary removal operations. Self-reinforced fixation devices are safe and efficient for the treatment of pediatric mandible fractures. However, further clinical investigations are needed to evaluate long-term reliability.

Reducing Risks for Midface and Mandible Fracture Repair

The midface skeleton provides structural scaffolding to the middle third of the face. Complications associated with fracture repair in these regions can result from incomplete, inaccurate, or delayed assessment, poor initial and subsequent reduction and fixation, infection, uncontrolled hemorrhage, hardware failure and associated soft tissue injuries. A systematic approach to managing the patient with facial trauma that includes Acute Trauma Life Support principles, early reconstruction, and precise reduction and fixation is essential to reducing the short-term and long-term risks of complications.

Emergency versus semi-elective management of mandible fractures: a Maxillofacial Trainee Research Collaborative (MTReC) study

INTRODUCTION

Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures.

METHODS

A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications.

RESULTS

Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030).

CONCLUSION

Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.

Classification of unusual fracture patterns of the mandible: A retrospective study

The aim of this study is to devise and summarize a classification of fracture patterns involving multiple anatomical sites of the mandible. A retrospective study was conducted by reviewing clinical case records, imaging records, and the surgical management of patients presenting with mandibular fracture. Demographic data were collected and causes of the fractures were studied. Following radiological evaluations based on the courses of fracture lines, these fractures were categorized into three components: horizontal (H), vertical (V), and sagittal (S). In case of horizontal components, the mandibular canal was used as a reference. For vertical components, the fracture lines were classified according to where they terminated. With sagittal components, the direction of the bicortical split at the base of mandible was used as a reference. Out of a total of 893 mandibular trauma patients, 30 unusual fractures were identified (21 in males and nine in females), which do not fit into existing classifications. These were mainly due to road traffic accidents. Horizontal components of fractures were classified as H-I, H-II, and H-III, and vertical components as V-I, V-II, and V-III. For sagittal components, two types were identified - S-I and S-II - resulting in a bicortical split of the mandible. This classification is proposed to help understanding the complex fractures and to allow standardized communication among clinicians. Moreover, it is designed in such a way that aids in the choice of fixation technique. Further studies are needed to establish standardized treatment algorithms for efficient management of these unusual fractures.

Transoral Endoscopic-Assisted Reduction and Internal Fixation of Mandibular Condylar Fractures in Children

PURPOSE

Extraoral approaches for open reduction and fixation of condylar fractures in children are associated with serious risks of complications, including facial nerve injury, facial scarring, parotid fistula, and auriculotemporal nerve injury. The purpose of this study was to retrospectively evaluate the outcomes of transoral endoscopic-assisted open reduction and internal fixation of condylar fractures and hardware removal in pediatric patients.

MATERIAL AND METHODS

This study was designed as a retrospective case series. The study included pediatric patients admitted with condylar fractures that were indicated for treatment with open reduction and internal fixation. The patients were clinically and radiographically evaluated with regard to occlusion, mouth opening, lateral and protrusive movement of the mandible, pain, chewing and speech difficulties, and bone healing at the fracture site. Computed tomography images were used to assess the reduction of the fractured segment, the stability of fixation and progress of healing of the condylar fracture at follow-up visits. The same surgical treatment approach was applied to all patients. The data from the study were analyzed for a single group without any comparison to other groups.

RESULTS

The technique was used for the treatment of 14 condylar fractures in 12 patients between the ages of 3 to 11 years. A total of 28 transoral endoscopic-assisted approaches to the condylar region either for reduction and internal fixation or hardware removal were applied. The mean operating time was 53.1 (±11.3) minutes for the fracture repair and 20 (±2.6) minutes for hardware removal, respectively. The mean follow-up time of the patients was 17.8 (±2.7) months (median: 18) months. All patients regained stable occlusion, satisfactory mandibular motion, stable fixation, and complete bone healing at the fracture site at the end of their follow-up period. There was no transient of permanent facial nerve or trigeminal nerve injury in any of the patients.

CONCLUSIONS

Endoscopically assisted transoral approach is a reliable technique for reduction and internal fixation of condylar fracture and hardware removal in pediatric patients. The serious risks of extraoral approaches including facial nerve injury, facial scar, and parotid fistula can be eliminated by using this technique.