Mandibular nerve block can improve intraoperative inferior alveolar nerve visualization during sagittal split mandibular osteotomy

Do Regional Nerve Blocks During Bimaxillary Surgery Decrease Postoperative Pain and Vomiting Compared With Patient-Controlled Analgesia?

BACKGROUND

Postoperative pain after orthognathic surgery is commonly managed with opioids, which can cause nausea and vomiting.

PURPOSE

The purpose of this study was to determine whether regional nerve blocks during bimaxillary surgery reduced postoperative pain and vomiting compared with patient-controlled analgesia (PCA).

STUDY DESIGN, SETTING, AND SAMPLE

This retrospective cohort study recruited patients who underwent bimaxillary surgery between August 2018 and September 2020 at the Fourth Military Medical University Hospital. Participants whose procedures involved the cheekbone, temporomandibular joint, mandibular angle, or an autogenous iliac bone graft and those who were admitted to the intensive care unit after surgery were excluded.

PREDICTOR VARIABLES

The primary predictor variables were postoperative analgesia management, regional maxillary and inferior alveolar nerve blocks, and PCA.

OUTCOME VARIABLES

The primary outcome variables were moderate-to-severe postoperative pain and postoperative vomiting (POV) during the first 24 hours. Moderate-to-severe pain was defined as pain numerical rating scale ≥4, POV was defined as vomiting of gastrointestinal contents.

COVARIATES

The study covariates included demographic, surgical, and anesthesia characteristics.

ANALYSES

Statistical analyses were conducted using an unpaired t-test, χ2 test, or Fisher's exact test for the bivariate analysis. A multivariate logistic regression analysis was performed to assess the associations between the primary predictor variables and outcomes. Statistical significance was set at P < .05.

RESULTS

354 participants were included in the study (262 in the nerve block group, mean age 22.5 ± 4.0 years; 92 in the PCA group, mean age 22.6 ± 4.4 years; P = .81). There was no significant difference in sex between the groups (63.4 and 55.4% females in nerve block and PCA groups, respectively, P = .18). The multivariate regression analyses demonstrated that nerve blocks did not decrease moderate-to-severe postoperative pain (7.6 vs 10.9%, adjusted odds ratio = 0.67, 95% confidence interval: 0.22-2.01, P = .48), although they were associated with decreased POV (38.5 vs 65.2%, adjusted odds ratio = 0.34, 95% confidence interval: 0.18-0.65, P = .001).

CONCLUSION AND RELEVANCE

For bimaxillary surgery, regional nerve blocks as opioid-free postoperative analgesia were not significantly associated with decreased postoperative pain but were associated with a lower POV risk.

Optimizing drug regimens and supplementation in orthognathic surgery: A comprehensive and practical guide

OBJECTIVE

This study aimed to comprehensively review the literature and provide a practical guide for optimizing drug regimens and supplementation related to orthognathic surgery.

METHODS

The authors conducted a thorough review of the existing literature, following the PRISMA-ScR guidelines. Various types of studies except case reports and reviews were included. The study applied specific inclusion criteria, focusing on perioperative and/or postoperative drugs, medications, or supplementation related to orthognathic surgery.

RESULTS

This guide included 78 studies on various medications in orthognathic surgery. It encompasses clinical trials, cohort studies, cross-sectional studies, prospective and retrospective studies. The topics covered include antibiotics, analgesics, corticosteroids, antiemetics, hemostatic agents, local anesthetics, herbal medicine, and botulinum toxin. Pain and edema control involved specific medications, while local anesthesia utilized ropivacaine and bupivacaine. The guide also discusses mineral and vitamin supplementation. The effectiveness of hemostatic agents and antiemetics was highlighted.

CONCLUSION

Pain management, reduced swelling, enhanced wound healing, and faster recovery are among the advantages. In addition to the standard drugs and medications, the inclusion of vitamin and mineral supplements, tranexamic acid, postoperative anesthetic blocks, and preemptive antiemetics is anticipated to offer various benefits in orthognathic surgery, despite the limited available evidence.

Systematic mapping review of orthognathic surgery

STUDY DESIGN

Systematic mapping review AIM AND SCOPE: The objective of this mapping review was to identify, describe, and organize clinical research currently available from systematic reviews and primary studies regarding co-interventions and different surgical modalities used in orthognathic surgery (OS) and their outcomes.

METHODS

Systematic reviews (SRs), randomized controlled trials, and observational studies that evaluated perioperative OS co-interventions and surgical modalities were identified in an exhaustive search of MEDLINE, EMBASE, Epistemonikos, Lilacs, Web of Science, and CENTRAL. Grey literature was also screened.

RESULTS

Included were 35 SRs and 253 primary studies, 103 from SRs, and another 150 identified in our search. Overall, SR quality was rated as critically low, with only two SRs rated as of high quality. 19 questions on population, interventions, comparisons, and outcomes (PICO) extracted from the SRs focused on osteosynthesis methods, surgical cutting devices, and use of antibiotics, corticosteroids, and induced hypotension. Also identified were 15 research gaps. Evidence bubble maps were created to graphically depict the available evidence.

CONCLUSION

Future high-quality research, both primary and secondary, is needed to address the knowledge gaps identified in this systematic mapping review.

Effect of epinephrine on the distribution of ropivacaine and lidocaine using radioactive isotopes in rat maxilla and pulp

We compared the effect of epinephrine on the distribution of ropivacaine and lidocaine by using radioactive isotopes in rat maxilla and pulp. Twenty microliters of 3H-labeled 0.5% ropivacaine, 14C-labeled 2.0% lidocaine, or epinephrine-supplemented isotopes were injected into the maxilla. The radioactivity was measured and autoradiography was obtained. Epinephrine led to increase in amounts of both anesthetics in the maxilla and pulp; however, each anesthetic did so in a different manner. Addition of epinephrine to lidocaine decreased radioactivity in maxilla and pulp with time. Conversely, when ropivacaine with epinephrine was administered, radioactivity did not change until 20 min in the maxilla and reached its peak at 20 min in the pulp. Autoradiography of lidocaine faded with time even with epinephrine use; however, with ropivacaine, higher accumulation image was observed after 20 min compared to that after 2 min. When epinephrine was combined with lidocaine, the amount of lidocaine in maxilla and pulp decreased with time, similar to when lidocaine was used alone. Conversely, when ropivacaine-epinephrine combination was administered, the amount of ropivacaine remained unchanged for 20 min in the maxilla and reached its peak at 20 min in the dental pulp.

Assessment of conduction anesthesia effectiveness using the angulated needle approach for the inferior alveolar nerve block

BACKGROUND

Ambulatory painless surgery is dependent on local anesthesia effectiveness.

AIM

Evaluating the anesthetic efficacy of the angulated needle approach (ANA) for the inferior alveolar nerve block (IANB).

MATERIAL AND METHOD

Group I received direct IANB; group II received indirect IANB; group III received the IANB with ANA. The quality of anesthesia score (QAS), numerical pain intensity score (NRS), onset time of full anesthesia (OT), and perianesthetic complications were measured.

RESULTS

Ninety patients (mean age: 37.47 ± 18.90, p = 0.027) of both sexes were split into three equal groups. Group III had the lowest QAS value with the success rate of 93.3%, compared to the statistically significantly worse QAS values of group II, with the success rate of 80% (p = 0.016). Group II had the statistically significant highest NRS values relative to group I (p = 0.002) and group III (p = 0.000001). The shortest OT occurred in group I, when compared to group II (p = 0.000484) and group III (p = 0.000498). The transient syncope and positive aspiration occurred in single cases.

CONCLUSION

The ANA for the IANB could successfully serve as a "first choice", or as an "addendum technique" in the cases of multiple failed attempts for direct and indirect IANB techniques.

The benefit of bilateral inferior alveolar nerve block in managing postoperative nausea and vomiting (PONV) after mandibular osteotomy

INTRODUCTION

The purpose of our study was to evaluate the benefit of bilateral inferior alveolar nerve block (BIANB) in managing postoperative pain, nausea and vomiting and opioid and antiemetic consumption in mandibular osteotomy.

MATERIAL AND METHODS

51 patients operated for bilateral sagittal split osteotomy (BSSO) were included in this prospective randomized controlled, double-blind, superiority trial. In the first group (n = 25), standard protocol was applied (general anesthesia and postoperative multimodal analgesia). The second group (n = 26) received bilateral inferior alveolar nerve block anesthesia at the start of surgery in addition to routine protocol. Postoperative monitoring was conducted every 4 h over the first 24 h and targeted the following criteria: postoperative nausea and vomiting (PONV), the visual analog scale (VAS) for pain, consumption of morphine (cumulative dose) and antiemetic agents, need for removal of guiding elastics.

RESULTS

PONV was significantly lower in the BIANB group (15.4 % VS 40 %, p = 0.049), as were mean VAS scores for pain (1 VS 1.57, p = 0.045) and medians of morphine bolus (8 [6-16] VS 5.5 [1-8], p = 0.033). We found no significant difference in incidence of guiding elastic removal, and antiemetic consumption.

DISCUSSION

The use of BIANB in BSSO improved postoperative patient comfort in terms of PONV and pain. Furthermore, it led to a decrease in opioid consumption. In conclusion, it is an additional therapeutic means of improving patients' postoperative comfort.

Pilot study in France about the infiltration of local anaesthetics associated to oral surgery procedures performed under general anaesthesia

Introduction: Opinions differ regarding the combined use of local anaesthesia (LA) and general anaesthesia (GA) in oral surgery procedures. The aim of this study was to evaluate practices in France concerning intraoperative LA for oral surgery performed under GA. Practitioners and method: We conducted a prospective survey of 250 oral surgery practitioners (CNIL-2045135v0 e) and carried out a literature review with the MEDLINE search engine (PubMed) covering the period from January 2000 to September 2017. Results: Among the 77 practitioners who participated, 88.3% were dental practitioners, the majority of whom were in the 25–34-yr age group. More than half (59%) infiltrated the surgical site; 46% pre-operatively, 24% intraoperatively and 11% post-operatively. Discussion: LA under GA appears to have advantages for post-operative pain management, dissection of the first mucosal plane and bleeding management pre- and post-operatively. The contraindications remain the same as for patients in a vigilant state. In children, it should be used in moderation to limit the risk of self-inflicted lip or mouth trauma during recovery. Conclusion: The indications of LA under GA are operator-dependent and the analysis of the literature did not allow us to determine the interest or not of LA administered intraoperatively during oral surgery performed under GA.

Prevention of Bleeding in Orthognathic Surgery--A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

The objective of the present study was to evaluate the efficacy of hemostatic adjuncts on intraoperative blood loss (IOB) in orthognathic surgery (OS) detected by randomized controlled trials (RCTs) of the highest quality.

MATERIALS AND METHODS

A search of the Medline, Cochrane, Embase, and Web of Science databases was performed in January 2015, and the risk of bias was assessed using the Jadad and Delphi scales. The predictor variable was the hemostatic measures, and the main outcome variable was the total IOB volume. The secondary outcome variables were the hemoglobin and hematocrit and operating time. This review is registered at PROSPERO (CRD42014014840).

RESULTS

Eleven trials were included for review. The individual trials demonstrated the effects on IOB from hypotensive anesthetic regimens, the use of aprotinin, and the herbal medicine Yunnan Baiyao. Six studies of tranexamic acid (TXA), with 288 patients, were suitable for a meta-analysis of continuous data. TXA reduced IOB by an average of 171 mL (95% confidence interval [CI] -230 to -112; P < .00001). Its topical use yielded similarly significant results (mean difference -197, 95% CI -319 to -76; P < .001). A subgroup analysis showed a decreased operating time in the TXA groups by an average of 15 minutes (mean difference -14.78, 95% CI -22.21 to -7.35; P < .0001).

CONCLUSIONS

Efficient hemostatic adjuncts exist for OS. Our meta-analysis showed that TXA significantly reduces IOB by an average of one third, regardless of whether it was given intravenously (IV) or applied topically. Additional RCTs are needed to confirm the effect of topical TXA in OS, and larger studies of intravenous administration are needed before any routine recommendations. No hemostatic effect of hypotensive anesthesia was found, mainly owing to imprecise descriptions of the blinding procedures. Transparent and uniform trial reporting is thus encouraged in future studies.

Lower-level laser therapy improves neurosensory disorders resulting from bilateral mandibular sagittal split osteotomy: a randomized crossover clinical trial

Bilateral sagittal split osteotomy (BSSO) is a technique commonly used to correct mandibular disproportion but many patients experience hypoaesthesia of the inferior alveolar nerve (IAN). The purpose of this study was to verify the effectiveness of using a low-level laser therapy protocol after BSSO. The 10 patients in our study, who underwent BSSO with Le Fort I osteotomy and had low-level laser therapy on one side of the jaw, were evaluated over a period of 60 days. The data for the treated and non-treated sides were compared post-operatively. At 15, 30 and 60 days after surgery, when sensitivity was recovered on both sides. On the treated side, recovery was faster and was almost complete at the time of the last evaluation. We suggest that this lower-level laser therapy protocol can improve tissue response and accelerate the recovery of neurosensory disorders following BSSO. (NCT01530100).