Complications and the Time to Repair of Mandible Fractures

Mandibular fracture scoring system: for prediction of complications

INTRODUCTION

Mandibular fractures are one of the most commonly encountered injuries in trauma clinics. Although several widely accepted classification systems exist, these are mostly region specific, differ in the classification criteria used, and are sometimes only correlated with specific treatment modalities, thereby making it impossible to uniformly and comprehensively document facial fracture patterns. In this study, we developed a modified scoring system for mandibular fractures and analyzed the relationship between scoring of fractures that were treated and the incidence of complications after surgical treatment.

MATERIALS AND METHODS

To evaluate the suitability of the proposed scoring system, a prospective study on a series of 116 patients was performed. All the fractures were classified using the proposed scoring system. The scoring was based on clinical and radiological evaluation of each fracture. Patients were followed up postoperatively for presence of complications.

RESULTS

A good correlation between the proposed scoring system and the incidence of complications was detected.

DISCUSSION

This scoring system for mandibular fractures facilitates an objective and standardized assessment of the degree of severity of a fracture, thereby allowing for systematic evaluation of facial fracture outcomes, including assessment of complications. However, it is our understanding that a multicenter study should be performed before the effectiveness of the proposed classification can be clearly stated.

Pearls of mandibular trauma management

Mandibular trauma is a common problem seen by plastic surgeons. When fractures occur, they have the ability to affect the patient's occlusion significantly, cause infection, and lead to considerable pain. Interventions to prevent these sequelae require either closed or open forms of reduction and fixation. Physicians determining how to manage these injuries should take into consideration the nature of the injury, background information regarding the patient's health, and the patient's comorbidities. Whereas general principles guide the management of the majority of injuries, special consideration must be paid to the edentulous patient, complex and comminuted fractures, and pediatric patients. These topics are discussed in this article, with a special emphasis on pearls of mandibular trauma management.

A review of mandibular angle fractures

AFTER STUDYING THIS ARTICLE, THE READER WILL BE ABLE TO: (1) review the incidence and etiology of mandibular angle fractures; (2) gain an understanding of patient evaluation and general management principles; and (3) discuss indications and available techniques for management of mandibular angle fractures. Angle fractures represent the highest percentage of mandibular fractures. Two of the most common causes of mandibular angle fractures are motor vehicle accidents and assaults or altercations. With any patient who has sustained facial trauma, a thorough history and comprehensive physical examination centering on the head and neck region as well as proper radiological assessment are essential. These elements are fundamental in establishing a diagnosis and developing an appropriate treatment plan for any mandibular fracture.

A comparison of outcomes between immediate and delayed repair of mandibular fractures

Medical records of patients treated with surgical repair of mandible fractures by the otolaryngology and plastic surgery departments at a level 1 trauma centre were obtained and reviewed. Two study groups were compared: patients treated within 72 h of the injury and those treated after this time period. Patient demographics, time to repair, fracture types, substance abuse history, etiology, surgical management, complications and length of hospital stay were assessed. The complication rate was 41% (n=7) within the immediate group and 38% (n=6) within the delayed group (P=0.56). Complications were prevalent in patients with history of substance abuse in both groups. Complication rates did not increase when repair of mandible fractures was delayed beyond 72 h, while substance abuse was a factor in increasing complications rates. Outpatient triage with elective repair of isolated mandibular fractures appears to be more cost-effective than admission with inpatient management.

Delays in emergency oral and maxillofacial operations: 5 years later

Delays in emergency oral and maxillofacial operations lead to prolonged discomfort for patients and increase the burden on acute hospital services. A published prospective study in our unit in 2003-2004 identified appreciable delays, which were primarily attributed to general surgical cases taking priority (system delay). Our aim in the present study was to assess progress since then by making a prospective audit of delays in emergency oral and maxillofacial operations over a 6-month period. Data collected included duration and reason for delays, and these were correlated with type of operation, and compared to the performance in the same hospital 5 years previously.A total of 222 patients were booked on to the emergency list, which indicated that the workload had doubled during the 5 years. Mean delay had also increased, with 60% of patients waiting more than 12h, and 29% more than 24h. Fractured mandibles were most likely to be left. System delay accounted for 83% of delays. There had been no lessening of the delays in emergency operating, despite increased use of elective lists for emergencies. This may be attributed to the large increase in workload without matching increases in the number of staff or availability of theatres. In addition, problems with communication between specialties, the number of staff in theatre and recovery, and over-running of elective lists, contributed to the use of theatres that did not match their capacity. Since the end of the audited period there have been signs of improvement as a result of an interspecialty initiative to improve the productivity of emergency theatres, and the addition of a dedicated trauma list for oral and maxillofacial surgery.

Analysis of results in early versus late midface fracture repair

OBJECTIVE

To evaluate the complication rate in relation to the timing of surgical repair of midface fractures.

STUDY DESIGN AND SUBJECTS

Retrospective chart review at a level 1 trauma center.

RESULTS

Thirty-four patients were evaluated. Overall complication rate was 23.5% with no significant difference between the early repair (21.1%) and late repair (26.7%) groups. The scope of facial fracture repair was similar between the two groups as measured by the number of screws used and through an injury quantifying system. The only variable that tended toward significance was intraoperative blood loss, which was greater in the early repair group (P = 0.06).

CONCLUSIONS

There is no clear consensus with respect to timing of midface trauma repair. Early repair may result in greater blood loss. Further study is needed to help establish a more precise recommendation for the timing of midface trauma repair.

Posttraumatic Mandibular Deformities

In covering the Emergency Department, the Plastic Surgeon can be faced with the mandibular fracture patient. Although the timely repair of the fracture usually leads to normal function and appearance, occasionally the surgeon is faced with the untoward sequelae of the mandible fracture. Post-traumatic mandibular deformities include non-union, malunion, malocclusion, TMJ dysfuction, and facial asymmetry. The difficulty in treatment of these deformities can be compounded by edentulous mandibles, substance abuse, and approach controversies such as the timing of the repair and surgical versus non-surgical management. Knowledge of the post-traumatic mandibular deformities by the treating physician not only assists in their management but may also allow for their prevention.

Management of Mandible Fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Review the incidence and etiology of mandible fractures. 2. Discuss indications and techniques for closed and open treatment of mandible fractures. 3. Review complications of mandible fractures.

BACKGROUND

Mandible fractures are among the most common types of facial fractures treated by plastic surgeons. They must be managed carefully to maintain the function of the mandible, reestablish proper occlusion, and minimize secondary complications.

METHODS

Current methods of management include combinations of soft diet, intermaxillary fixation, open reduction with plate fixation, and, rarely, external fixation.

RESULTS

Decision-making depends on the age of the patient, type of fracture identified, and concomitant medical conditions or injuries.

CONCLUSION

The authors review the diagnosis and current trends in management of mandible fractures.