Mandibular fracture scoring system: for prediction of complications

Analysis of Surgical Complications in Mandibular Fractures in the Center of Italy: A Retrospective Study

Mandibular fractures are the second most common maxillofacial fractures. The prevalent treatment for this kind of fractures is either a surgical procedure such as maxillomandibular fixation or open reduction and internal fixation or a combination of both. Sometimes the patients might develop locoregional postoperative complications. The most frequently reported complications are trigeminal V3 injury and surgical site infection. A 4-year retrospective study was performed at the Department of Oral and Maxillofacial Surgery, Policlinico Umberto I of Rome, Italy, and the postoperative complications after mandibular fracture surgical treatment were collected. The authors studied the characteristics of each complication and the correlation with the type of mandibular fracture and the surgical treatment chosen.

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.

Tooth in the line of a mandibular fracture: Retain it or remove it? Clinical case report

Defining the prognosis and treatment plan for teeth in the line of a mandibular fracture is a challenge for the maxillofacial surgeon. The periodontal ligament may provide a communication with the oral cavity and become a pathway for infection. There is currently no consensus on the management of teeth in mandibular fracture lines. This report outlines a case where a tooth was successfully retained in the line of fracture as well as providing a review of the literature on the best-accepted treatments for this scenario.

Correlating the Bony Facial Trauma Score with Clinical Outcomes

Background: In 2017, the Bony Facial Trauma Score (BFTS) was developed to quantify and describe bony trauma of the face. Objective: To compare BFTSs for the need of hospital admission, intensive care unit (ICU) admission, surgery, tracheostomy tube placement, cervical spine (c-spine) injury, and mortality. Methods: A retrospective review of patients sustaining bony facial trauma from January 1, 2017 to November 30, 2019 was done. Logistic regression modeling measured the association between BFTS and admission status, need for operative repair, tracheostomy, mortality, ICU admission, and c-spine injury. Results: Three hundred six patients were included for this analysis. Median BFTS was 3.5 (interquartile range, 5), while the average age was 45.0 years (standard deviation, 22.3). The most common mechanisms of injury were motor vehicle accident (44.8%) and ground-level fall (32.5%). BFTS was found to correlate with the following (p < 0.05): admission (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.13), mortality (OR 1.05, 1.00-1.10), tracheostomy (OR 1.11, 1.07-1.17), operative management (OR 1.16, 1.11-1.22), ICU (OR 1.07, 1.03-1.11), and c-spine injury (OR 1.05, 95% CI 1.03-1.11). Conclusion: A significant correlation was found between BFTS and all the outcomes investigated.

Assessing Adult Patients with Facial Deformities for Injectable Treatment: Do Current Classification Systems and Methodologies Meet Important Patient Needs?

BACKGROUND

Many individuals are affected by facial deformities. Injectable aesthetic treatments can often be used to improve appearance and/or dynamic function. However, to best meet the needs of these patients, broadly applicable methodologies are required for classifying the deformity, assessing severity, and developing a treatment strategy.

OBJECTIVE

To assess whether any published systems could be used for this purpose.

METHODS

Thirty-eight searches were conducted in PubMed (1999-2019; in English). Forty-two publications were identified describing novel classification systems for adult facial deformity. They were analyzed against a checklist of 10 characteristics defining an "optimal" system-based on appropriate anatomical coverage, wide usability across types of deformity, user-friendliness, applicable underlying methodology, and ability to guide treatment with injectables.

RESULTS

None of the systems met more than 7 of the 10 checklist criteria; none were usable across multiple types of deformity or provided a recommendation for treatment with injectables.

CONCLUSION

There remains a need for a broadly applicable system for classifying adult facial deformities ahead of injectable therapy. The checklist provides a developmental framework. With the increasing popularity and accessibility of injectables, this diverse and complex demographic is at risk of mismanagement without superior methods for devising treatment strategies.

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Analysis of factors that influence quality of life of individuals undergoing treatment for mandibular fractures: A systematic review and meta-analysis

OBJECTIVE

To address the factors that affect the quality of life (QoL) of individuals undergoing treatment for mandibular fractures.

STUDY DESIGN

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the search strategy was constructed according to the Populations, Interventions, Comparison, Outcomes, and Study Design principle in the following databases: PubMed, Web of Science, Scopus, and EMBASE. Risk of bias assessment was performed with Risk Of Bias In Non-randomized Studies of Interventions and Cochrane Risk of Bias tool for randomized trials 2.

RESULTS

Nineteen studies were included: 15 observational and 4 clinical trials. Mean age ranged from 28 to 39 years, with a higher proportion of males. The condyle was the main fracture location and traffic accident was the fracture cause. Treatment approaches were mostly open reduction (89.4%) and maxillomandibular fixation (63%). QoL measurements varied considerably with the General Oral Health Assessment Index (31.5%) and Oral Health Impact Profile-14 (21%) as the main instruments. Meta-analysis showed that open reduction and maxillomandibular fixation did not present significant differences to QoL (P = .39), but significant differences were observed with time (P < .00001). Other factors affected QoL, such as mental health, pain, socializing, appearance, and eating difficulties.

CONCLUSIONS

Several factors, apart from the treatment approach, mentioned in this review seemed to affect the QoL of patients with mandibular trauma. Treatment choice should be based on well-stablished clinical criteria and on all other factors mentioned here.

The effect of lockdown during SARS-CoV-2 pandemic on maxillofacial injuries in a level I trauma centre: a comparative study

INTRODUCTION

The SARS-CoV-2 pandemic forced many governments to impose nation-wide lockdowns. Government legislation forced limited travel on the population with restrictions on the normal way of life to limit spread of the SARS-CoV-2 virus. The aim of this study is to explore the effects of lockdown on the presentation of maxillofacial trauma in a level I trauma centre.

METHODS

Comparative analysis was carried out using prospective and retrospective review of all consecutive patients admitted with any maxillofacial fracture in the lockdown period between 15th March and 15th June 2020 with the same period in 2019 to a Regional Trauma Maxillofacial Surgery Unit. Data included basic demographics and mechanism of injury including alcohol/drug influence, polytrauma, site of injury and treatment modality including escalation of care.

RESULTS

Across both periods, there were a total of one hundred and five (n = 105) recorded episodes of traumatic fractures with fifty-three (n = 53) in the pre-lockdown cohort and fifty-two (n = 52) in the lockdown. Included patients were significantly (p = 0.024) older during lockdown (mean age 41.44 years SD 20.70, range 5-96) with no differences in gender distribution between cohorts (p = 0.270). Patients in lockdown were more likely to be involved in polytrauma (p < 0.05) and have sustained their injury by cycling/running or any outdoor related activity (p = 0.013). Lockdown saw a significant reduction in alcohol and drug related violence (p < 0.05). Significantly more patients required operative management (p = 0.038).

CONCLUSION

Local lockdowns form part of the governments public health strategy for managing future outbreaks of SARS-CoV-2. Our study showed no significant reduction in volume of trauma during lockdown. It is vital that hospitals maintain trauma capacity to ensure that patients are treated in a timely manner.

Prognosis of teeth in mandibular fracture lines

BACKGROUND/AIMS

Teeth in a jaw fracture line, because of the presence of the periodontal ligament, may communicate with the oral cavity. There are no guidelines for the management of teeth in mandibular fracture lines. The aim of this study was to investigate the factors related to dental problems with teeth involved in mandibular fracture lines and to determine the best treatment option.

MATERIAL AND METHODS

This retrospective study was based on the medical and radiographic records of patients with mandibular fractures. The relationships among the patient's age, gender, smoking history, amount of bony displacement, surgery, trauma-surgery period, apical involvement, tooth mobility, and periodontal status were investigated. Group comparisons were performed using the chi-squared test, Fisher's exact test, and Mann-Whitney U-test.

RESULT

A total of 238 patients (247 fracture lines) with mandibular fractures including a tooth in the line of the fracture were examined. Post-operative dental complications occurred in 42 cases (17.0%). Extraction of related teeth occurred in 34 cases (80.9%) compared to eight cases (19.0%) related to root canal therapy. This study defined "dental problem" as "a case with a tooth extracted or endodontically treated after trauma." The variables associated with an increased risk of dental problems were the amount of bony displacement (p < .01), tooth mobility (p < .01), and pre-existing marginal alveolar bone loss (p = .027).

CONCLUSION

The prognosis of teeth in mandibular fracture lines was related to tooth mobility, periodontal state, and the amount of bony displacement.

Arteriovenous Fistula after Mandibular Fracture: A Case Report

We described a rare case of arteriovenous (AV) fistula after mandibular fracture in a 64-year-old man with chronic schizophrenia. The diagnosis was made by CT angiography. The patient suffered two episodes of mandibular fracture 3 months and 12 months ago. He was found to have a large AV fistula in left side of his neck. So the patient was scheduled for operation to correct fistula.

Changes in mandibular and articular dynamics associated with surgical versus nonsurgical treatment of mandibular condylar fractures: a systematic review with meta-analysis

OBJECTIVE

The aim of this study was to evaluate the mandibular and articular dynamics and the presence of complications associated with surgical or nonsurgical treatments of condylar fractures.

STUDY DESIGN

Clinical trials that compared open reduction internal fixation and maxillomandibular fixation in patients with condylar fractures were included. We performed an electronic search of PubMed, Scopus, Cochrane Library, Web of Science, and LILACS (Latin American and Caribbean Health Sciences) databases starting from February 2017 and updated in January 2019 and found 467 articles. We evaluated methodologic quality by using the criteria from Cochrane's Collaboration Tool.

RESULTS

After independent screening of abstracts, we assessed the full texts of 88 articles; 9 studies were included for qualitative synthesis; but only 8 were included for the meta-analysis. Four studies were considered to have high risk of bias, and 5 were considered to have low risk. The risk ratio (RR = 0.20; 95% confidence interval [CI] 0.13-0.32) was observed for complications. The quality of evidence, using GRADE software, was considered low for maximum mouth opening and protrusive movement and moderate for lateral excursion movement and complications.

CONCLUSIONS

This review suggested that open reduction internal fixation and maxillomandibular fixation are effective. However, surgical treatment presented higher objective parameters. Nonsurgical treatment presented a high index of complications, such as malocclusion, pain and deviation.

Outcomes research: Mandibular fractures in the diabetic population

OBJECTIVE

The study aimed to examine the management and outcomes of mandibular fractures in patients with diabetes mellitus by examining the injury modalities, treatment methods, and complications.

METHODS

The study conducted was a retrospective case review of patients admitted to Memorial Hermann Hospital from 2007 to 2011 with diagnoses of diabetes mellitus and mandibular fracture. The electronic medical records were reviewed for patient demographics, injury data, surgery methodology, treatment variables, and complications.

RESULTS

Out of the 34 diabetic patients, the average age was 52 with the majority of the fractures being the result of falls, 12 (35.3%). Of the 63 total fractures, 24 (38.1%) fractures were repaired through closed reduction and 39 (61.9%) fractures required open reduction with internal fixation. 17 (50.0%) patients had at least one complication following mandibular fracture repair. The most common complications in this sample population included nerve injury, 7 (20.6%), infection, 7 (20.6%), wound dehiscence with or without hardware exposure, 6 (17.7%), and malocclusion, 5 (14.7%).

CONCLUSION

When compared to the limited published data our findings imply that diabetic patients with mandibular fractures present as an older population than commonly seen with mandibular fractures and suggest a higher overall rate of complications.

Teeth in the line of mandibular fractures

PURPOSE

This study aims to review the literature regarding the evolution of current thoughts on the management of teeth in the line of mandibular fractures (MFs).

METHODS

An electronic search in PubMed was undertaken in June 2012. The titles and abstracts from these results were read to identify studies within the selection criteria-studies reporting clinical series of MFs in which the management of teeth in the fracture line was analyzed.

RESULTS

The search strategy initially yielded 731 references. Twenty-seven studies were identified without repetition within the selection criteria. Additional hand searching yielded 12 additional papers.

CONCLUSIONS

It is suggested that rigid fixation systems and the use of antimicrobial agents have reduced the incidence of infection in cases of teeth in the line of MFs. Tooth buds in the line of MFs should not be removed or replaced in the (alleged) proper position despite the degree of displacement, since studies showed that even tooth buds in the early stage of calcification and those involved in widely displaced fracture sites continued development and erupted. Its removal should be considered in cases of infection, which is a predictive factor of abnormality and/or impaction. Intact teeth in the fracture line should be left in situ if they show no evidence of severe loosening or inflammatory change. Permanent teeth maintained in the line of fracture should be followed up clinically and radiographically for at least 1 year to ensure that any unnecessary endodontic treatment is avoided. Teeth in the line of fracture that prevents reduction of fractures, teeth with fractured roots, a partially impacted wisdom tooth with pericoronitis, and a tooth with extensive periapical lesion should be removed. Teeth in the line of MFs should also be removed when located in sites where there is extensive periodontal damage, with broken alveolar walls, resulting in the formation of a deep pocket (making optimal healing doubtful).