A Clinical Comparison and Economic Evaluation of Erich Arch Bars, 4-Point Fixation, and Bone-Supported Arch Bars for Maxillomandibular Fixation

Does Maxillomandibular Fixation Technique Affect Occlusion Quality in Segmental LeFort I Osteotomy?

BACKGROUND

Segmental maxillary osteotomies require precise occlusal control due to variability in individual segment positioning. The role of maxillomandibular fixation (MMF) technique on occlusal control has not been validated.

PURPOSE

The purpose is to measure and compare the accuracy of occlusal positioning among MMF techniques.

STUDY DESIGN, SETTING, SAMPLE

This was a double-blinded in vitro study on experiment models to simulate a 3-piece LeFort I osteotomy. The models were constricted posteriorly and expanded using 3 different MMF techniques and compared to the unaltered baseline occlusion. Based on sample size calculation, 32 separate attempts were made for each MMF technique.

PREDICTOR VARIABLE

The predictor variable was MMF technique (brackets, MMF screws, and embrasure wires).

MAIN OUTCOME VARIABLES

The primary outcome variable was the visual occlusal analysis score, a 1.00 to 4.00 continuous scale measuring the similarity of the achieved occlusion to the planned (control) occlusion assessed by an oral and maxillofacial surgeon and an orthodontist. High visual occlusal analysis score indicated greater occlusal accuracy, with 3.50 defined as the threshold for accuracy. The secondary outcome variable was the linear error of the achieved occlusion at the canine and first molar teeth, with lower error indicating greater accuracy. An a priori accuracy threshold of 0.5 mm was set for this variable.

COVARIATES

None.

ANALYSES

Kruskal-Wallis test with post hoc testing was used to analyze the difference in the outcome variables of interest. P value < .05 was considered statistically significant.

RESULTS

Thirty-two attempts for each technique showed that brackets had higher VAOS than MMF screws and embrasure wires (median differences 1.49 and 0.48, P < .001), and had lower linear occlusal error (median differences 0.35 to 0.99 mm, P < .001).

CONCLUSION AND RELEVANCE

MMF technique influences the quality of occlusal control, with greater visual rating scores and lower linear errors seen with brackets than with embrasure wires or MMF screws.

Healthcare costs of different treatment options for condylar fractures

Objective

As treatment options for condylar fractures have comparable outcomes, getting insight into associated costs is a first step towards implementing value-based healthcare (VBH). Therefore, we described the actual costs of the different treatment options (surgical, conservative, and expectative treatment) for condylar fractures. We expected surgical treatment to be the most expensive treatment.

Study design

This is a cost-of-illness study, based on estimates from the literature. Firstly, care pathways of all treatment options were described. Secondly, the costs per step were calculated based on the literature and Dutch guidelines for economic evaluations in health care.

Results

The direct treatment costs of surgical treatment (€3721 to €4040) are three to five times higher than conservative treatment (€730 to €1332). When lost productivity costs during the recovery period are included, costs of surgical treatment remain 1.5 times higher (€9511 to €9830 for surgical treatment and €6224 to €6826 for conservative treatment). The costs of expectative treatment (€5436) are lower than both other treatments.

Conclusion

The costs for surgical treatment are considerably higher than those for conservative or expectative treatment, mainly related to direct treatment cost. Future research should focus on the patients' perspective, to support implementation of VBH in treating condylar fractures.

Is manual reduction adequate for intraoperative control of occlusion during fixation of mandibular fractures? A systematic review and meta-analysis

The aim of this systematic review was to find out if manual intraoperative control of occlusion is adequate for the reduction of mandibular fractures in comparison with intermaxillary fixation (IMF). We searched PubMed, Embase, the Cochrane Library and Clinical Trials Registry, and the references of included trials. Our primary outcomes of interest were the reduction of fracture anatomically and radiographically, occlusal disturbances, and the incidence of revision procedures due to poor occlusion or reduction. Our secondary outcomes of interest were operating time and infective complications. Of the 257 studies retrieved (manual reduction = 136, IMF = 121), four were included. The studies had an unclear risk of bias. Nevertheless, the overall effect was statistically significant and in favour of manual reduction, with a lower number of adverse events in the manual reduction group (n = 43) than in the IMF group (n = 78), odds ratio 0.42 (95% CI 0.27 to 0.64). An absolute reduction in adverse events was seen in occlusion disturbances (120 fewer/1000), revision procedures (164 fewer/1000), and infective complications (178 fewer/1000). The evidence to support manual reduction over IMF for the intraoperative control of fracture fragments and occlusion was derived from few studies with an unclear risk of bias, and the quality was low. The results were not different when condylar fractures were present. The overall certainty of evidence was moderate. Clinicians should select the appropriate technique based on the injury pattern, and the treating surgeon's experience and available resources.