Pearls of mandibular trauma management

Morbidity of Teeth in Mandibular Fracture Lines - A Retrospective Study

BACKGROUND/AIM

Teeth in mandibular fracture lines is common in maxillofacial trauma, but their retention or extraction is a matter of controversy. The aim of this study was to determine the factors related to retaining or extracting teeth situated in mandibular fracture lines and to decide the best treatment option.

METHODS

The study included 115 patients with a single mandibular fracture that had a tooth in the line of fracture. All patients were evaluated for complications and pulp status. Patient distribution was analyzed according to the complications that occurred. Statistical analysis was performed using SPSS 13.0 software.

RESULTS

There were significant effects of tooth type and tooth location on the occurrence of complications. There were no significant differences in the occurrence of complications between the retained teeth group and the extracted teeth group irrespective of age and gender in adult patients. There were significant differences in treatment procedures between the retained teeth group and the extracted teeth group.

CONCLUSION

Mandibular anterior teeth involved in the fracture line should be retained, while in the mandibular angle area, they should be extracted because retaining teeth in this region increases the prediction of complications. There is no role of pulp testing in the assessment of pulp status, but root canal treatment of retained teeth helps to reduce the occurrence of complications. This article is protected by copyright. All rights reserved.

The skeletal trauma resulting from a fatal B.A.S.E jump: A case study showing the impact of landing feet-first under extreme vertical deceleration

The term 'B.A.S.E jump' refers to jumping from a building, antenna, span (i.e., bridge) or earth (i.e., cliff) structure, and parachuting to the ground. There are numerous hazards associated with B.A.S.E jumps which often result in injury and, occasionally, fatality. This case report details the skeletal trauma resulting from a fatal B.A.S.E jump in Australia. In this case, the jumper impacted the ground from a fall of 439m in a feet-first landing position, as a result of a partially deployed parachute, under extreme vertical deceleration. Skeletal trauma was analyzed using full-body post mortem computed tomography (PMCT) and contextual information related to the circumstances of the jump as reported by the Coroner. Trauma to 61 skeletal elements indicates the primary impact was to the feet (i.e., feet-first landing), followed by an anterior impact to the body (i.e., fall forwards). Details of the individual fracture morphologies indicate the various forces and biomechanics involved in this fall event. This case presents the types of fractures that result from a B.A.S.E jump, and highlights the value of using PMCT and coronial data as tools to augment skeletal trauma interpretations.

The use of Synthes MatrixWAVE bone anchored arch bars for closed treatment of multiple concurrent mandibular fractures

Background

Maxillomandibular fixation (MMF) is an important tool in the treatment of facial fractures and bone-anchored arch bar systems have emerged as treatment options. This study illustrates our experience with the Synthes MatrixWAVE MMF system and the novel application in closed treatment of patients with multiple concurrent mandibular fractures.

Methods

We enrolled eight patients with concurrent mandibular fractures and treated them with the MatrixWAVE MMF system. The malleable arch bars were fitted and then secured using 6-8 mm screws. The arch bar was and either stretched or compressed to ensure optimal positioning. 24-gauge interdental fixation wiring was placed using the fish loop technique on either side of the fracture to achieve stabilization of the mandible fractures.

Results

All eight patients were retained in MMF until stable occlusion was achieved with clinical evidence of healing, approximately 4-6 weeks. Post-operative Panorex scans did not reveal any evidence of damage to tooth roots. None of the screws became overly embedded in the mucosa secondary to overgrowth; the arch bars were successfully removed in an outpatient setting without local anesthesia.

Conclusions

The Synthes MatrixWAVE MMF system has unique features such as prominent screw anchor heads and horizontal malleability unique from other bone anchored arch bars. These features allow for completely closed treatment of patients with multiple concurrent mandible fractures.

Is The Late Mandibular Fracture From Third Molar Extraction a Risk Towards Malpractice? Case Report with the Analysis of Ethical and Legal Aspects

Objectives

The present study reports a case of late mandibular fracture due to third molar extraction and highlights the inherent clinical, ethical and legal aspects related to this surgical complication.

Material and Methods

A female patient underwent surgical procedure for the extraction of the mandibular right third molar. Two days after the surgery the patient reported pain and altered occlusion in the right side of the mandible. After clinical and radiographic re-examination, the diagnosis of late mandibular fracture was established. A second surgery, under general anaesthesia, was performed for the fixation of the mandibular bone.

Results

The fractured parts were reduced and fixed with locking plate systems and 2 mm screws following load-sharing principles. The masticatory function showed optimal performance within 7 and 21 days after the surgery. Complete bone healing was observed within 1 year of follow-up.

Conclusions

For satisfactory surgical outcomes, adequate surgical planning and techniques must be performed. Signed informed consents explaining the risks and benefits of the treatment must be used to avoid ethical and legal disputes in dentistry.

Single Miniplate Fixation for Mandibular Symphysis and Parasymphysis Fracture as a Viable Alternative to Conventional Plating Based on Champy's Principles: A Prospective Comparative Clinical Study

To compare long term and short term outcomes of fixing mandibular symphysis and parasymphysis fractures with single mini plate and conventional fixation using two mini plates.

STUDY DESIGN

in this prospective clinical comparative study, 30 patients with fracture in study region were randomly divided into two groups. Group A patients received single 2.5 mm titanium miniplate and Group B patients received two 2 mm titanium miniplates as per Champy's lines of osteosynthesis. Patients were followed up at intervals of 1, 12 and 24 weeks. Parameters assessed were: duration of surgery, fracture stabilization, paresthesia, occlusion and wound dehiscence. Statistically significant difference was observed in mean duration of surgery and wound dehiscence (P < 0.05). No significant difference was observed with respect to other parameters. Single 2.5 mm miniplate for mandibular symphysis and parasymphysis fractures is a time saving and cost effective technique with post-operative outcomes similar to conventional 2 plate fixation.

Unusual Spontaneous Mandibular Regeneration of a Large Defect Followed by Orthodontics, Alveolar Distraction, and Dental Implant Rehabilitation: A 10-Year Follow-Up

This report describes an atypical case of spontaneous mandibular regeneration of a large size bony defect after resection of an aseptic osteonecrotic area near the symphysis and parasymphyseal area. The patient underwent orthodontic therapy, vertical osteogenic distraction of the alveolar bone, and oral rehabilitation with an implant borne prosthesis. This case study also describes the 10-year follow-up of comprehensive multidisciplinary treatment and successful recovery of a patient's esthetic and functional aspects.

Isolated bilateral mandibular angle fractures: an extensive literature review of the rare clinical phenomenon with presentation of a classical clinical model

Bilateral angle fractures are a rare clinical phenomenon in contrast to the incidence of unilateral angle fractures. However, the rarity has garnered less attention in spite of the uniqueness of fracture pattern and distinctive biomechanics. This article is a detailed review on the etiology, clinical presentation, and management of bilateral angle fractures with the presentation of an interesting case. The bilateral angle fracture reported is a untreated, malunited fracture representing an ideal clinical model to study its biomechanics. The clinical features were anterior open bite, increased facial height, and temporomandibular joint tenderness. The management included osteotomy at the malunion and miniplate osteosynthesis. Bilateral angle fracture presents mandible in three independent fragments (left angle, right angle, and intermediate corpus), each with strong muscles acting in different vectors. This makes the fracture vulnerable to severe displacing forces and unfavorable to achieve the optimal reduction, stability, and healing. This necessitates comprehension of the biomechanical forces involved to avoid malunion following fixation. The article details the complex biomechanics of mandibular angle and its clinical implications in the rare event of bilateral angle fractures. It describes the necessity for a systematic approach and ideal osteosynthesis principles to achieve maximal treatment outcomes and minimal complications.

Facing the airway challenges in maxillofacial trauma: A retrospective review of 288 cases at a level i trauma center

BACKGROUND

Maxillofacial trauma is an apt example of a difficult airway. The anesthesiologist faces challenges in their management at every step from airway access to maintenance of anesthesia and extubation and postoperative care.

METHODS

A retrospective study was done of 288 patients undergoing surgery for maxillofacial trauma over a period of five years. Demographic data, detailed airway assessment and the method of airway access were noted. Trauma scores, mechanism of injury, duration of hospital stay, requirement of ventilator support were also recorded. Complications encountered during perioperative anaesthetic management were noted.

RESULTS

259 (89.93%) of the patients were male and 188 (62.85%) were in the 21-40 year range. 97.57% of the cases were operated electively. 206 (71.53%) patients were injured in motor vehicular accidents. 175 (60.76%) had other associated injuries. Mean Glasgow coma scale score (GCS), injury severity score (ISS) and revised trauma score (RTS) were 14.18, 14.8 and 12, respectively. Surgery was performed almost nine days following injury. The mean duration of hospitalization was 16 days. ICU admission was required in 22 patients with mean duration of ICU stay being two days. Majority of patients had difficult airway. 240 (83.33%) patients were intubated in the operating room and fibreoptic guided intubation was done in 159 (55.21%) patients. Submental intubation was done in 45 (14.93%) cases.

CONCLUSIONS

Maxillofacial injuries present a complex challenge to the anaesthesiologist. The fibreoptic bronchoscope is the main weapon available in our arsenal. The submental technique scores over the time-honored tracheostomy. Communication between the anaesthesiologist and the surgeon must be given paramount importance.

Mandibular trauma treatment: a comparison of two protocols

Objectives: The aim of this study was to evaluate the treatment of mandibular fractures treated in two European centre in 10 years. Study Design: This study is based on 2 systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures in two centers in Turin, Italy and in Amsterdam, the Netherlands for ten years. Only patients who were admitted for mandibular fractures were considered for this study. Results: Between 2001 and 2010, a total of 752 patients were admitted at Turin hospital with a total of 1167 mandibular fractures not associated with further maxillofacial fractures, whereas 245 patients were admitted at Amsterdam hospital with a total of 434 mandibular fractures. At Amsterdam center, a total of 457 plates (1.5 - 2.7 mm) were used for the 434 mandibular fracture lines, whereas at Turin center 1232 plates (1.5 – 2.5 mm) were used for the management of the 1167 mandibular fracture lines. At Turin center, 190 patients were treated primarily with IMF, whereas 35 patients were treated with such treatment option at Amsterdam center. Conclusions: Current protocols for the management of mandibular fractures are quite efficient. It is difficult to obtain a uniform protocol, because of the difference of course of each occurring fracture and because of surgeons’ experiences and preferences. Several techniques can still be used for each peculiar fracture of the mandible.

Key words:Mandibular fracture, facial trauma, maxillofacial, treatment, multicentre, database.

[Intermaxillary intraoperative fixation of mandibular fractures: arch bars or fixation screws?]

INTRODUCTION

The gold standard management of mandibular fractures is open reduction and osteosynthesis associated with intermaxillary fixation. The use of intermaxillary fixation screws for 20 years has considerably reduced the number of intermaxillary fixation with arch bars. The aim of our review was to identify current indications and contraindications of each technique.

INTERMAXILLARY FIXATION TECHNIQUES

We present a short history and compare the two techniques with recently published assets, drawbacks, and complications.

DISCUSSION

The indications of intermaxillary fixation screws are uni- or bifocal fractures without or with minimal displacement. Their use is contraindicated in any other type of fracture, which should still be treated with arch bar fixation.