A randomized controlled trial on cross-infection control in maxillofacial trauma surgery: A comparison of intermaxillary fixation techniques

Erich arch bars vs intermaxillary fixation screws for mandibular fracture reduction during ORIF: a randomized clinical trial

OBJECTIVE

This randomized clinical trial aimed to compare the efficacy of Erich arch bars (EAB) and intermaxillary fixation (IMF) screws in reducing mandibular fractures during open reduction and internal fixation (ORIF).

METHODS

A total of 28 patients with mandibular fractures were randomly allocated to either the EAB group or the IMF screws group. The study evaluated various parameters including occlusal stability, complications, duration of application, oral hygiene status, quality of life, and patient characteristics.

RESULTS

The study found no significant differences in occlusal stability between the EAB and IMF screw groups. However, the application and removal times were longer for EAB compared to IMF screws. The EAB group showed a higher presence of biofilm on teeth, indicating poorer oral hygiene status compared to the IMF screws group. In terms of quality of life, patients in the EAB group reported worse results in the "handicap" domain at the 15th postoperative day. No significant differences were observed in other quality-of-life parameters. Patient characteristics were well distributed between the two groups, enhancing the reliability of the results.

CONCLUSION

Both EAB and IMF screws demonstrated comparable occlusal stability for minimally displaced mandibular fractures. However, IMF screws offered advantages such as shorter application and removal times, better oral hygiene maintenance, and potentially improved quality of life in the "handicap" domain. Further studies with larger sample sizes are necessary to validate these findings and explore the stability of IMF methods in cases requiring postoperative malocclusion correction or prolonged IMF.

The Assessment of Intermaxillary Fixation and Open Reduction Using Skeletal Anchorage System Compared With Arch Bar in Mandible Fracture Based on CT Image

BACKGROUND

There are many different techniques to achieve intermaxillary fixation (IMF) for open reduction of mandible fractures. The arch bar has long been used as the gold standard of IMF to assist open reduction. However, owing to its long operating time, risk of needle stick injury, and gingival trauma, surgeons looked into different treatment options for IMF, such as the skeletal anchorage system (SAS). Therefore, this study aimed to compare the stability between IMF with arch bar and IMF with SAS based on computed tomography image.

MATERIALS AND METHODS

In this retrospective study, postoperative computed tomography and panoramic radiographs were taken 1 week and 6 months after surgery, respectively. The treatment of mandibular fractures using IMF with arch bar and SAS were compared by evaluating changes in the dental midlines and condyle positions. Thirty patients with mandibular fractures were enrolled into 2 groups-IMF with arch bar and IMF with SAS.

RESULTS

The arch bar showed slightly more deviation in dental midline. In SAS, the condyle moved more medially compared with the arch bar.

CONCLUSIONS

Skeletal anchorage system could be used for IMF with reliable stability in mandible fracture. There were no significant differences in the treatment outcome between the 2 groups.

Focus on the use of maxillomandibular fixation in mandibular fracture oseosynthesis

OBJECTIVES

The objective of this study was to evaluate the efficiency of three methods of isolated mandibular fracture intraoperative reduction.

MATERIALS AND METHODS

This 6-year retrospective study included patients with isolated extra-articular mandibular fractures who would benefit from osteosynthesis. The endpoint was postoperative occlusion according to the type of intraoperative immobilization: screws, arch, or manual reduction.

RESULTS

A total of 145 patients were included, with 233 fractures. Forty-five patients underwent manual reduction without maxillo-mandibular fixation (MMF), 51 MMF with screws, and 49 MMF with arch, with 11.1%, 5.9% and 4.1% of patients in these groups experiencing postoperative malocclusion, respectively. The overall malocclusion rate was 6.9%. There was no significant difference among the 3 methods according to univariate statistical analysis (p = 0.42) or after comparing MMF (grouping screws and arches) to manual reduction without MMF (p = 0.29).

CONCLUSION

This study did not show a significant difference between the different methods of intraoperative reduction of isolated extra-articular mandibular fractures, even though intraoperative MMF was much more commonly used for complex fractures. However, there is a non-significant tendency to get a better post-operative occlusal result with MMF, which remains the reference traitement. Intraoperative manual reduction without MMF may be used within trained teams in some instances.

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.

FAMI Screws for Mandibulo-Maxillary fixation in mandibular fracture treatment - Clinico-radiological evaluation

Mandibulo-maxillary fixation (MMF) is indispensable for mandibular fracture treatment. Various means for MMF have been proposed, of which arch bars are widely considered to be the mainstay. However, disadvantages to this method have initiated a quest for an alternative, leading to the introduction of MMF screws. MMF screws have frequently been criticized for poor stability of fracture sites, root damage, hardware failure, and nerve damage. We retrospectively evaluate the FAMI (Fixation and Adaptation in Mandibular Injuries) screw in mandibular fracture treatment by scanning for clinically and radiologically visible complications. In total, 534 FAMI screws were used in the successful treatment of 96 males and 34 females. Condylar fractures were most commonly encountered, representing 120 of 241 fracture sites. 15 general fracture-related complications occurred, with the most common being nerve function impairment (3.8%) and postoperative malocclusion (4.6%). In nine cases (7%), clinically visible FAMI-screw-related complications occurred, with the most prevalent being screw loosening (2.3%) and mucosal signs of inflammation (3.1%). Duration of FAMI screws was associated with the occurrence of clinically visible complications (p = 0.042). Radiologically, clinically invisible dental hard tissue damage was noted in 21 individuals (16%). Therefore, FAMI screws seem to be a reliable and safe method for mandibulo-maxillary fixation.

The use of mini plates for intermaxillary fixation in a severely comminuted mandibular fracture with bilateral condylar fractures

Intermaxillary fixation (IMF) is an integral technique utilized by maxillofacial surgeons to appropriately reduce and relate maxillary and mandibular fractures to both one another and the facial skeleton. This case report reviews the management of a comminuted mandibular fracture including inoperable bilateral condylar fractures that precluded the use of convention IMF techniques necessitating an alternative technique. This was achieved in the form of modified bony plates extending intraorally. Postoperative review showed favorable results with occlusion and range of motion comparable to the premorbid function and no unforeseen complications.

Hardware Removal in Craniomaxillofacial Trauma: A Systematic Review of the Literature and Management Algorithm

Background

Craniomaxillofacial (CMF) fractures are typically treated with open reduction and internal fixation. Open reduction and internal fixation can be complicated by hardware exposure or infection. The literature often does not differentiate between these 2 entities; so for this study, we have considered all hardware exposures as hardware infections. Approximately 5% of adults with CMF trauma are thought to develop hardware infections. Management consists of either removing the hardware versus leaving it in situ. The optimal approach has not been investigated. Thus, a systematic review of the literature was undertaken and a resultant evidence-based approach to the treatment and management of CMF hardware infections was devised.

Materials and Methods

A comprehensive search of journal articles was performed in parallel using MEDLINE, Web of Science, and ScienceDirect electronic databases. Keywords and phrases used were maxillofacial injuries; facial bones; wounds and injuries; fracture fixation, internal; wound infection; and infection. Our search yielded 529 articles. To focus on CMF fractures with hardware infections, the full text of English-language articles was reviewed to identify articles focusing on the evaluation and management of infected hardware in CMF trauma. Each article’s reference list was manually reviewed and citation analysis performed to identify articles missed by the search strategy. There were 259 articles that met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There were 81 grade II articles included in the meta-analysis.

Result

Our meta-analysis revealed that 7503 patients were treated with hardware for CMF fractures in the 81 grade II articles. Hardware infection occurred in 510 (6.8%) of these patients. Of those infections, hardware removal occurred in 264 (51.8%) patients; hardware was left in place in 166 (32.6%) patients; and in 80 (15.6%) cases, there was no report as to hardware management. Finally, our review revealed that there were no reported differences in outcomes between groups.

Conclusions

Management of CMF hardware infections should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for management of CMF hardware infections based on this critical review of the literature is presented and discussed.

Evaluation of two different methods of arch bar application: a comparative prospective study

PURPOSE

To comparatively evaluate the efficacy of a pencil type wire twister and the normal wire twister in terms of various parameters during arch bars application.

METHOD

The study involved residents of the department enrolled in MDS course. Two study groups of 60 patients each were made by randomly selecting the patients from the outpatient department of Oral and Maxillofacial surgery who required arch bar application. Group A included the patients who underwent upper and lower arch bar application with the use of a pencil type twister and group B included patients who underwent arch bar application with a normal wire twister. All respondents were given a questionnaire after the completion of procedure involving the use of medical sharps. The paired samples t test was used for statistical analysis.

RESULT

Among group A, mean glove perforations, actual wire stick injuries, mean time taken to complete the procedure, mean wire breakage during the procedure was less than in group B. Comfort level of patients and Ease of operator while performing the procedure was more in group A than in group B. Frictional abrasion of the finger was not associated with the use of pencil type twister. Overall rating of the procedure was more in group A than group B.

CONCLUSION

The use of pencil type wire twister outweighs normal wire twister in various ways. It increases the overall efficacy of the operator during the procedure.

Novel Arch Bar Fabricated With a Computer-Aided Design and Three-Dimensional Printing: A Feasibility Study

PURPOSE

The aim of the present study was to evaluate the feasibility of the design and fabrication of a novel arch bar using 3-dimensional printing. Furthermore, the study assessed its use in a preliminary clinical study of intermaxillary fixation.

PATIENTS AND METHODS

Seven patients who met the inclusion criteria were enrolled in the present study. Plaster dental casts were created of each patient and scanned using cone-beam computed tomography to obtain digital casts. Computer-aided design software was then used to complete the virtual building of the arch bars, which were manufactured using 3-dimensional printing and a cobalt-chrome alloy. The clinical results were observed after the arch bars were fixed to the dentition with steel wires.

RESULTS

The arch bar contacted the dentition with a "surface-to-surface" pattern. The utility of these novel arch bars was verified by successfully fitting them to the dental arches of the patients. All the patients achieved their desired occlusion.

CONCLUSION

The results of the present study have illustrated that this digital method is feasible for constructing a novel arch bar, showing promise for clinical use.

Evidence-based medicine: Mandible fractures

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the anatomy and subunits of the mandible. 2. Review the cause and epidemiology of mandible fractures. 3. Discuss the preoperative evaluation and diagnostic imaging. 4. Understand the principles and techniques of mandible fracture reduction and fixation.

SUMMARY

The management of mandibular fractures has undergone significant improvement because of advancements in plating technology, imaging, and instrumentation. As the techniques in management continue to evolve, it is imperative for the practicing physician to remain up-to-date with the growing body of scientific literature. The objective of this Maintenance of Certification article is to present a review of the literature so that the physician may make treatment recommendation based on the best evidence available. Pediatric fractures have been excluded from this article.

Comparison of intermaxillary fixation screw versus eyelet interdental wiring for intermaxillary fixation in minimally displaced mandibular fracture: a randomized clinical study

PURPOSE

The aim of the present randomized study was to evaluate the efficacy of intermaxillary fixation screw (IMFS) versus eyelet interdental wiring for intermaxillary fixation (IMF) in minimally displaced mandibular fractures.

MATERIALS AND METHODS

A total of 50 patients with a minimally displaced mandibular fracture were enrolled, with 25 patients randomly selected for each group. In group I (study group, n = 25), the patients were treated using IMFS, and in group II (control group, n = 25), they received eyelet interdental wiring. Both techniques were assessed for the following parameters: time required for placement and removal of each type of IMF technique, time required for placement of IMF wires, postoperative occlusion, stability of the IMF wire, local anesthesia requirement during removal of each fixation type, oral hygiene status, glove perforation rate, and complications associated with both techniques. The collected data were analyzed using Student's unpaired t test or χ2 test. P < .05 was considered significant and the Statistical Package for Social Sciences software, version 10, was used for analysis.

RESULTS

The average time required for placement in groups I and II was 17.56 and 35.08 minutes, respectively (P = .000). The time required for placement of the IMF wire in group I was 2.1 minutes and in group II was 6 minutes. The oral hygiene status was assessed, and the mean plaque index score for groups I and II was 1.44 and 2.12, respectively (P = .00). The glove perforation rate was much less in group I than in group II. Finally, the most common complication in both groups was mucosal growth.

CONCLUSIONS

The results established the supremacy of IMFS compared with eyelet interdental wiring. Thus, we have concluded that IMFS, in the present scenario, is a safe and time-saving technique. IMFS is a cost-effective, straightforward, and viable alternative to cumbersome eyelet interdental and other wiring techniques for providing IMF, with satisfactory occlusion during closed reduction or intraoperative open reduction internal fixation of fractures. In addition, oral hygiene can be maintained, and the glove perforation rate was very low using IMFS. The relatively small sample size and limited follow-up period were the study limitations.

[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.

Interventions for the management of mandibular fractures

BACKGROUND

Fractures of the mandible (lower jaw) are a common occurrence and usually related to interpersonal violence or road traffic accidents. Mandibular fractures may be treated using open (surgical) and closed (non-surgical) techniques. Fracture sites are immobilized with intermaxillary fixation (IMF) or other external or internal devices (i.e. plates and screws) to allow bone healing. Various techniques have been used, however uncertainty exists with respect to the specific indications for each approach.

OBJECTIVES

The objective of this review is to provide reliable evidence of the effects of any interventions either open (surgical) or closed (non-surgical) that can be used in the management of mandibular fractures, excluding the condyles, in adult patients.

SEARCH METHODS

We searched the following electronic databases: the Cochrane Oral Health Group's Trials Register (to 28 February 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 1), MEDLINE via OVID (1950 to 28 February 2013), EMBASE via OVID (1980 to 28 February 2013), metaRegister of Controlled Trials (to 7 April 2013), ClinicalTrials.gov (to 7 April 2013) and the WHO International Clinical Trials Registry Platform (to 7 April 2013). The reference lists of all trials identified were checked for further studies. There were no restrictions regarding language or date of publication.

SELECTION CRITERIA

Randomised controlled trials evaluating the management of mandibular fractures without condylar involvement. Any studies that compared different treatment approaches were included.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trial quality and extracted data. Results were to be expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals. Heterogeneity was to be investigated to include both clinical and methodological factors.

MAIN RESULTS

Twelve studies, assessed as high (six) and unclear (six) risk of bias, comprising 689 participants (830 fractures), were included. Interventions examined different plate materials and morphology; use of one or two lag screws; microplate versus miniplate; early and delayed mobilization; eyelet wires versus Rapid IMF™ and the management of angle fractures with intraoral access alone or combined with a transbuccal approach. Patient-oriented outcomes were largely ignored and post-operative pain scores were inadequately reported. Unfortunately, only one or two trials with small sample sizes were conducted for each comparison and outcome. Our results and conclusions should therefore be interpreted with caution. We were able to pool the results for two comparisons assessing one outcome. Pooled data from two studies comparing two miniplates versus one miniplate revealed no significant difference in the risk of post-operative infection of surgical site (risk ratio (RR) 1.32, 95% CI 0.41 to 4.22, P = 0.64, I(2) = 0%). Similarly, no difference in post-operative infection between the use of two 3-dimensional (3D) and standard (2D) miniplates was determined (RR 1.26, 95% CI 0.19 to 8.13, P = 0.81, I(2) = 27%). The included studies involved a small number of participants with a low number of events.

AUTHORS' CONCLUSIONS

This review illustrates that there is currently inadequate evidence to support the effectiveness of a single approach in the management of mandibular fractures without condylar involvement. The lack of high quality evidence may be explained by clinical diversity, variability in assessment tools used and difficulty in grading outcomes with existing measurement tools. Until high level evidence is available, treatment decisions should continue to be based on the clinician's prior experience and the individual circumstances.

Manual reduction of mandibular fractures before internal fixation leads to shorter operative duration and equivalent outcomes when compared with reduction with intermaxillary fixation

PURPOSE

Open reduction of mandibular fractures before internal fixation is most commonly performed by 1 of 2 methods: intermaxillary fixation (IMF) or manual reduction. There are risks to both patient and clinician associated with using IMF. Furthermore, previous retrospective studies have failed to show any advantage in its use. The purpose of this study was to directly compare the use of manual reduction (experimental group) and IMF (control group) in open reduction-internal fixation of mandibular fractures.

MATERIALS AND METHODS

Patients who presented with isolated mandibular fractures at 2 hospitals in Queensland, Australia, from May 2009 to June 2010 were enrolled in a prospective controlled trial comparing IMF and manual reduction. The outcome measures were operative duration (primary outcome), as well as radiographic outcome, occlusal outcome, and complications (secondary outcomes). The patient and assessor were blinded to the type of reduction used before fixation. The study hypothesis is that manual reduction allows internal fixation in a shorter time than IMF with an equivalent outcome.

RESULTS

We recruited 50 patients, 26 allocated to IMF and 24 allocated to manual reduction before internal fixation of mandibular fractures. IMF was associated with an increased duration of procedure (P < .001) and increased complication rate (P = .063), without any observable benefit with regard to either radiographic outcome or occlusal outcome.

CONCLUSIONS

IMF is not required in open reduction-internal fixation of mandibular fractures that met our inclusion criteria. IMF is associated with increased costs to the health service and risks to both the patient and clinician.

Risk of surgical glove perforation in oral and maxillofacial surgery

Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves (n=1436) in 150 oral and maxillofacial surgeries including orthognathic surgery (n=45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3-48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects.

The Use of MMF Screws: Surgical Technique, Indications, Contraindications, and Common Problems in Review of the Literature

Mandibulo-maxillary fixation (MMF) screws are inserted into the bony base of both jaws in the process of fracture realignment and immobilisation. The screw heads act as anchor points to fasten wire loops or rubber bands connecting the mandible to the maxilla. Traditional interdental chain-linked wiring or arch bar techniques provide the anchorage by attached cleats, hooks, or eyelets. In comparison to these tooth-borne appliances MMF screws facilitate and shorten the way to achieve intermaxillary fixation considerably. In addition, MMF screws help to reduce the hazards of glove perforation and wire stick injuries. On the downside, MMF screws are attributed with the risk of tooth root damage and a lack of versatility beyond the pure maintenance of occlusion such as stabilizing loose teeth or splinting fragments of the alveolar process. The surgical technique of MMF screws as well as the pros and cons of the clinical application are reviewed. The adequate screw placement to prevent serious tooth root injuries is still an issue to rethink and modify conceptual guidelines.