Treatment outcomes with the use of maxillomandibular fixation screws in the management of mandible fractures

Resorbable engineered barrier membranes for oral surgery applications

Population aging, reduced economic capacity, and neglecting the treatments for oral pathologies, are the main causal factors for about 3 billion individuals who are suffering from partial/total edentulism or alveolar bone resorption: thus, the demand for dental implants is increasingly growing. To achieve a good prognosis for implant-supported restorations, adequate peri-implant bone volume is mandatory. The Guided Bone Regeneration (GBR) technique is one of the most applied methods for alveolar bone reconstruction and treatment of peri-implant bone deficiencies. This technique involves the use of different types of membranes in association with some bone substitutes (autologous, homologous, or heterologous). However, time for bone regeneration is often too long and the bone quality is not simply predictable. This study aims at engineering and evaluating the efficacy of modified barrier membranes, enhancing their bioactivity for improved alveolar bone tissue regeneration. We investigated membranes functionalized with chitosan (CS) and chitosan combined with the peptide GBMP1α (CS + GBMP1α), to improve bone growth. OsseoGuard® membranes, derived from bovine Achilles tendon type I collagen crosslinked with formaldehyde, were modified using CS and CS + GBMP1α. The functionalization, carried out with 1-ethyl-3-(3 dimethylaminopropyl)carbodiimide and sulfo-N-Hydroxysuccinimide (EDC/sulfo-NHS), was assessed through FT-IR and XPS analyses. Biological assays were performed by directly seeding human osteoblasts onto the materials to assess cell proliferation, mineralization, gene expression of Secreted Phosphoprotein 1 (SPP1) and Runt-Related Transcription Factor 2 (Runx2), and antibacterial properties. Both CS and CS + GBMP1α functionalizations significantly enhanced human osteoblast proliferation, mineralization, gene expression, and antibacterial activity compared to commercial membranes. The CS + GBMP1α functionalization exhibited superior outcomes in all biological assays. Mechanical tests showed no significant alterations of membrane biomechanical properties post-functionalization. The engineered membranes, especially those functionalized with CS + GBMP1α, are suitable for GBR applications thanks to their ability to enhance osteoblast activity and promote bone tissue regeneration. These findings suggest a potential advancement in the treatment of oral cavity problems requiring bone regeneration.

Maxillomandibular Fixation: Understanding the Risks and Benefits of Contemporary Techniques in Adults

Numerous techniques achieve maxillomandibular fixation (MMF), each with benefits and risks. While using Erich arch bars to achieve MMF has remained the gold standard through the last century, the technique has multiple limitations, which have spurred innovative approaches, such as intermaxillary fixation (IMF) screws, hybrid arch bars, embrasure wires, and dental occlusion ties. The surge in new MMF technologies over the past decade prompted this analysis to compare these techniques. A PubMed search was conducted to identify all current FDA-approved modern MMF technologies from 2005 through 2023, evaluating their advantages and limitations. Studies with controlled scientific comparisons of techniques were limited, precluding a systematic review. Analysis showed no definitive data exist to endorse one technique as a universal option. As multiple MMF options offer appropriate stability, a surgeon may choose an approach based upon numerous factors: comminution/instability; need for physiotherapy, including guiding elastics; safety; time of application/removal; and patient comfort. This article guides the selection between techniques based on these factors and presents a decision algorithm to assist surgeons in selecting the ideal MMF technique for each patient.

Lower Insertional Torque of Fixation Screws for Mandibular Angle Fractures Is Associated With Complications

BACKGROUND

Open reduction and internal fixation (ORIF) is a common treatment for mandibular angle fractures. It is unknown, however, whether the insertional torque of the fixation screws is a risk factor for postoperative complications.

PURPOSE

The purpose of the study was to determine the association between fixation screw insertional torque and postoperative inflammatory complications (POICs).

STUDY DESIGN, SETTING, SAMPLE

The authors conducted a prospective cohort study consisting of all adult patients treated with ORIF of mandibular angle fractures using a single six-hole lateral border plate secured with monocortical screws from January 1, 2020, to October 31, 2022, at a large, urban academic hospital. Patients with gunshot wounds, prolonged maxillomandibular fixation, and bilateral angle fractures were excluded.

PREDICTOR VARIABLE

The predictor variables were the average and lowest insertional torque of the six screws placed for fixation during ORIF.

MAIN OUTCOME VARIABLE

The outcome variable was the presence of POICs, defined as the occurrence of exposed or infected hardware, abscess formation, recurrent swelling/pain, nonunion, osteomyelitis, or fistula formation.

COVARIATES

Demographics, medical history, mechanism, diagnosis, and treatment-related variables were also analyzed.

ANALYSES

Descriptive and bivariate analyses were performed. A P value of ≤ .05 was considered significant.

RESULTS

There were 51 patients included in the study, 37 (72.5%) men, with a mean age of 31.2 ± 10.1 years. POICs occurred in 15.7% of patients. The average insertional screw torque was 46.9 ± 7.8 Ncm, and the mean lowest insertional screw torque per plate was 34.3 ± 10.2 Ncm. The average torque values were not lower in patients who had POICs versus those who did not (45.0 ± 8.6 Ncm vs 48.4 ± 7.6 Ncm, respectively, P = .16). However, the lowest torque value was less in patients who had POICs compared to those who did not (27.5 ± 11.0 Ncm vs 35.6 ± 9.7 Ncm, respectively, P = .04).

CONCLUSION AND RELEVANCE

Among patients with mandibular angle fractures treated with ORIF, decreased insertional torque for the lowest of the six screws placed for fixation was associated with complications. While previous studies have shown certain plating schemes have been associated with complications, the quality of fixation also plays a role.

Patient outcomes and complications following various maxillomandibular fixation techniques: A systematic review and meta-analysis

PURPOSE

Currently, there are several methods of achieving maxillomandibular fixation (MMF), each with its unique operative considerations and subsequent patient outcomes and complications. In this study, we reviewed the literature to evaluate and compare all MMF methods.

METHODS

A systematic review of all MMF types was conducted and post-operative outcome data were analyzed and compared among the different types. Conventional Erich arch bars were compared to hybrid arch bars, MMF screws, and eyelet interdental wiring. A random-effects meta-analysis was used to determine the mean differences, and 95% confidence intervals (CIs) with a statistical significance of P < 0.05.

RESULTS

Among the 4234 articles identified, 24 were included, and 17 were meta-analyzed. Time to achieve MMF (-43.38 min; 95% CI, -58.20 to -28.56; P < 0.001), total operative time (-30.33 min; 95% CI, -61.05 to 0.39; P = 0.05), incidence of wire puncture injuries and glove perforations (0.11; 95% CI, 0.04 to 0.30; P < 0.001), and incidence of poor oral hygiene (0.08; 95% CI, 0.02 to 0.28; P < 0.001) were lower for alternative MMF interventions compared to those of the conventional Erich arch bars.

CONCLUSIONS

Alternative MMF methods required shorter operative time to achieve MMF and demonstrated other increased efficiencies of practice such as shorter total operative time and decreased glove perforations, when compared to conventional Erich arch bars. If a patient is a candidate for MMF, the presented alternative MMF techniques should be considered depending on the clinical context and availability of institutional resources.

Control of Mandibular Width With 3D Printed Occlusal Splint in Children With Multiple Mandibular Fractures

BACKGROUND

The fracture of mandibular symphysis combined with bilateral condylar fractures often leads to changes in the width of the mandible, which significantly widens the face of the child. Therefore, it is necessary to reposition the mandible through accurate adduction.

METHODS

To ensure that the mandible can be accurately repositioned, a 3D printed occlusal splint was used. Bilateral maxillomandibular fixation screws were implanted. The 3D printed occlusal splint was located on the maxillary dentition and fixed to the maxillomandibular fixation screws with wire loops. The reference basis for adduction is to make the mandibular dentition located in the occlusal splint. The absorbable plate was contoured according to the restored model and fixed at the fracture site. The 3D printed occlusal splint was retained in the maxillary dentition for two months.

RESULTS AND DISCUSSION

Postoperative computed tomography showed that the mandible had been adducted according to the preoperative design. Two months of follow-up showed that the child's facial development, mouth opening type, occlusion, and range of motion were good. It is especially suitable for children with mandibular symphyseal fractures accompanied by bilateral condylar fractures.

Comparison of Efficacy and Safety of Hybrid Arch Bar with Erich Arch Bar in the Management of Mandibular Fractures: A Randomized Clinical Trial

Study Design

A clinical randomized control trial.

Objective

To compare the efficacy and safety of Hybrid arch bar (HAB) with Erich arch bar (EAB) in fracture management of the mandible.

Methods

In this randomized clinical trial, 44 patients were divided into 2 groups:- Group 1, N = 23 (EAB group) and Group 2, N = 21 (HAB group). The primary outcome was time taken for the application of arch bar, while the inner and outer glove puncture, operator prick, oral hygiene, arch bar stability, complications of HAB, and cost comparison were secondary outcomes.

Results

The time taken for the application of arch bar in group 2 was significantly shorter than group 1 (55.66 ± 17.869 min vs 82.04 ± 12.197 min) and the frequency of outer glove puncture was also significantly lesser for group 2 (0 punctures vs 9 punctures). Better oral hygiene was found in group 2. EAB was cost-effective than HAB (Rs 700 ± 239.79 vs Rs 1742.50 ± 257.14). The stability of the arch bar was comparable in both groups. Group 2 had associated complications of root injury in 2 out of 252 screws placed and the screw head got covered by soft tissue in 137 out of 252 screws placed.

Conclusions

Thus, HAB was better than EAB with a shorter time of application, less risk of prick injury, and improved oral hygiene.Clinical trial registry name- clinical trials registry- India, URL-http://ctri.nic.in, registration number- CTRI/2020/06/025966.

Treatment of pediatric bilateral condylar fractures: A comprehensive analysis

Pediatric bilateral condylar fractures (PBCF) is a rare clinical pathology, where the management is carried out with both conservative and surgical approaches. The purpose of this study was to analyze and compare these two treatment approaches and their associated long term complications in PBCF. An extensive literature review- through the search of online databases- was conducted to survey, collect, analyze and compare the reported outcomes of different treatment modalities for PBCF. The number of studies presenting PBCF case reports was 16, while the number of such retrospective studies included here was 19. Analyses of these studies revealed that the conservative treatment is preferred in PBCF patients younger than 12 years of age. Moreover, a composite approach where the open reduction and internal fixation (ORIF) is carried out for one side while the intermaxillary fixation (IMF) for the contralateral side is frequently reported for the management of PBCF cases; this approach appears effective in improving daily functioning of temporomandibular joint and reducing long term complications. Performing ORIF for one side while IMF for the contralateral side seems the most common treatment approach in PBCF. This study may help in rapid decision making for treatment selection of PBCF patients while minimizing the risk for late complications.

Bond Strength and Adhesion Mechanisms of Novel Bone Adhesives

Bone adhesives offer distinct advantages over the use of screws to attached internal fixation plates (IFPs). As the chemical composition of bone is similar to dentine, it is possible that the types of monomers used to make dentine adhesives could be utilised to affix IFPs to bone. The ability to attach a bio-resorbable IFP to porcine bone was assessed for the monomer 10-methacryloyloxydecyl dihydrogen phosphate (MDP), used either as a homopolymer or a copolymer with urethane dimethacrylate (MDP + U). Additionally, the addition of a priming step (MDP + U + P) was evaluated. The chemical interactions of the monomers with bone were assessed using XRD and imaged using TEM, revealing the formation of nano-layered structures with the MDP primer, something we believe has not been reported on bone. In a 6-week artificial aging study both MDP + U and MDP + U + P demonstrated adequate shear bond strength to affix bio-resorbable IFPs. The cytotoxicity profiles of the adhesive formulations were determined using indirect and direct contact with MC3T3 cells, with indirect conditions suggesting the MDP + U + P is as cytocompatible as the resorbable IFP. The findings of this study suggest our newly developed adhesive has the potential to be used as a bone adhesive to affix bioresorbable IFPs.

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.

Reliability and accuracy of the torque applied to osteosynthesis screws by maxillofacial surgeons and residents

Applying the right torque to osteosynthesis screws is important for undisturbed bone healing. This study aimed to compare test-retest and intra-individual reliabilities of the torque applied to 1.5 mm and 2.0 mm osteosynthesis screws by residents and oral and maxillofacial surgeons (OMF-surgeons), to define the reference torque intervals, and to compare reference torque interval compliances. Five experienced OMF-surgeons and 20 residents, 5 of each 4 residency years, were included. Each participant inserted six 1.5 × 4 mm and six 2.0 × 6 mm screws into a preclinical model at two test moments 2 weeks apart (T1 and T2). Participants were blinded for the applied torque. Descriptive statistics, reference intervals, and intra-class correlation coefficients (ICC) were calculated. The OMF-surgeons complied more to the reference intervals (1.5 mm screws: 95% and 2.0 mm screws: 100%) than the residents (82% and 90%, respectively; P = 0.009 and P = 0.007) with the ICCs ranging between 0.85-0.95 and 0.45-0.97, respectively. The residents' accuracy and reliability were inadequate regarding the 1.5 mm screws but both measures improved at T2 for both screw types compared to T1, indicating a learning effect. Training residents and/or verifying the applied torque by experienced OMF-surgeons remains necessary to achieve high accuracy and reliability, particularly for 1.5 mm screws.

Effect of Delay of Care for Patients with Craniomaxillofacial Trauma in Rwanda

Objectives

Craniomaxillofacial (CMF) trauma represents a significant proportion of global surgical disease burden, disproportionally affecting low- and middle-income countries where care is often delayed. We investigated risk factors for delays to care for patients with CMF trauma presenting to the highest-volume trauma hospital in Rwanda and the impact on complication rates.

Study Design

This prospective cohort study comprised all patients with CMF trauma presenting to the University Teaching Hospital of Kigali, Rwanda, between June 1 and October 1, 2020.

Setting

Urban referral center in resource-limited setting.

Methods

Epidemiologic data were collected, and logistic regression analysis was undertaken to explore risk factors for delays in care and complications.

Results

Fifty-four patients (94.4% men) met criteria for inclusion. The mean age was 30 years. A majority of patients presented from a rural setting (n = 34, 63%); the most common cause of trauma was motor vehicle accident (n = 18, 33%); and the most common injury was mandibular fracture (n = 28, 35%). An overall 78% of patients had delayed treatment of the fracture after arrival to the hospital, and 81% of these patients experienced a complication (n = 34, P = .03). Delay in treatment was associated with 4-times greater likelihood of complication (odds ratio, 4.25 [95% CI, 1.08-16.70]; P = .038).

Conclusion

Delay in treatment of CMF traumatic injuries correlates with higher rates of complications. Delays most commonly resulted from a lack of surgeon and/or operating room availability or were related to transfers from rural districts. Expansion of the CMF trauma surgical workforce, increased operative capacity, and coordinated transfer care efforts may improve trauma care.

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.

LeFort Fractures

Consultations for management of facial fractures in the emergency setting are not uncommon for the oral maxillofacial surgeon, otolaryngologist, and/or plastic surgeon. This necessitates a knowledge foundation and working understanding of the evaluation, assessment, and timely management. Here, we will focus on the workup and management of LeFort fractures.

Radiographic assessment of the response of teeth following trauma during screw placement for maxillo-mandibular fixation

BACKGROUND/AIM

Maxillo-mandibular fixation (MMF) screws have gained popularity in recent years for inter-maxillary fixation. MMF screw application involves the risk of dental injury. However, knowledge about the healing responses after root damage in humans is limited, thereby warranting the need to classify the radiographic assessment of healing to enable better prediction of the healing response and effective management of the potential complications. The aim of this study was to assess and classify the radiographic assessment of the responses after root damage to evaluate the long-term outcomes.

MATERIAL AND METHODS

The dental records of patients who underwent orthognathic surgery or trauma management during 2014-2016 at an Oral and Maxillofacial Surgery Department were retrospectively analyzed. The data regarding dental injuries resulting from MMF screw application were evaluated. In total, 16 patients with 34 roots damaged from MMF screw application were enrolled. Post-operative orthopantomographs were analyzed by visual inspection of the affected areas to clarify the extent of root healing. The inter- and intra-rater reliability assessments were subsequently performed.

RESULTS

The results indicated substantial inter- and intra-rater reliability of the responses. Most cases of root damage that were not radiographically related to the pulp (Schulte-Geers Class III defects) had complete or partial healing responses. In addition, 20% of the defects related to the pulp had additional resorption of the bone/dental tissues during the follow-up period.

CONCLUSIONS

Three different radiographic responses of root damage following MMF screw trauma were identified. Understanding these different responses is important to guide the management of the potential complications. This proposed radiographic assessment can be used to present root healing data in a more standardized and reliable manner.

The risk of tooth root injuries using cortical screws for intermaxillary fixation and osteosynthesis plates - A retrospective analysis

Intermaxillary fixation (IMF) and osteosynthesis plates (OP) are widely used for the non-surgical and surgical treatment of mandible and condyle fractures. The aim of this retrospective study was to analyze the frequency of tooth root injuries by IMF and OP screws. Electronic patient reports (2004-2013) were screened for patients treated with either IMF screws and/or OP in the Department of Oral- and Maxillofacial Surgery, University Medical Center Mainz, Germany. The frequency and the position of endangered and injured teeth were analyzed by orthopantomogram (OPTG) and cone beam computer tomography (CBCT). Next, possible predictive factors for tooth root injuries, namely interdental- and crestal distance, screw length and distance between tooth root and screw were evaluated. Further, the accuracy of OPTG vs. CBCT concerning the diagnosis of tooth root injuries was analyzed. Three-hundred sixty-six patients were included and 3388 teeth were defined as endangered by IMF- and OP screws. Overall, 16 injured teeth (0.5%) in 13 patients (3.55%) were detected. Nine injuries (56.3%) were caused by IMF- and seven injuries (43.8%) by OP screws. Three teeth were non-vital, one tooth had to be extracted. No correlation between the predictive factors crestal distance, screw length and tooth root injuries was found. If tooth injury occurred, a significant correlation between the interdental distance and the distance between tooth root and screw was found (κ = 0.48; p < 0,0001). Comparison between OPTG vs. CBCT demonstrated that many of the injuries that were seen in the OPTG (n = 230) could not be verified in the CBCT scans (n = 16) (κ = 0.12). To conclude, screws for IMF and OP can be considered as a safe procedure concerning the risk of tooth root injuries.

Antibiotic Duration and Outcome Complications for Surgical Site Infection Prevention in Traumatic Mandible Fracture

BACKGROUND

The appropriate duration of antibiotic therapy for surgical site infection (SSI) prevention in traumatic mandibular fracture repair is unknown, and practices vary significantly. The objective of this study was to characterize antibiotic duration and outcomes after surgical repair of traumatic mandibular fracture.

METHODS

A single-center, retrospective analysis of all adult patients who underwent surgical fixation of a mandible fracture between January 2014 and December 2016 was performed. Operative service was categorized between otolaryngology (ear, nose, and throat surgery), plastic and reconstructive surgery, and oral and maxillofacial services. Primary outcomes were SSI and operative complications (including osteomyelitis, nonunion, malocclusion, and hardware infections). Differences in antibiotic prescription pattern were analyzed using analysis of variance test and Pearson chi-squared test.

RESULTS

A total of 75 patients were included in the study with 33 (44.0%), 26 (34.7%), and 16 (21.3%) managed by plastic and reconstructive surgery, ear, nose, and throat surgery, and oral and maxillofacial services, respectively. Median age was 30.0 y. Median injury severity score was 4.0. There was no significant difference in hospital length of stay (P = 0.44), intensive care unit length of stay (P = 0.53), or postoperative complications (P = 0.15). None of our patients developed an SSI or postantibiotics complications. Although the total inpatient duration of antibiotics was not significantly different among services (P = 0.37), there were significant differences in outpatient duration of antibiotics (P = 0.007) and total duration of antibiotics (P = 0.003).

CONCLUSIONS

Duration of antibiotics is not associated with postoperative SSI or antibiotics-related complications. The wide variation in prescribing practices and lack of any clear benefit for prolonged antibiotics provides an opportunity to explore the benefits of a standardized short course of antibiotics.

LEVEL OF EVIDENCE

Therapeutic study, III.

Fracture propagation associated with intermaxillary fixation screws in maxillofacial trauma

Intermaxillary fixation (IMF) screws are commonly used for maxillomandibular immobilization in the management of mandible fractures as definitive closed reduction treatment or in adjunct intraoperatively. In this report, we present three cases of isolated unilateral mandible fractures, in which IMF screws were used and resulted in propagation of a second fracture on the contralateral side, at the site where IMF screws were placed during the surgery. The use of IMF screws has many advantages with an overall low risk of morbidity, however, there are potential complications that must be recognized.

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

Importance

Erich arch bars, 4-point fixation, and bone-supported arch bars are currently used in maxillomandibular fixation, although to what extent they differ in terms of overall charges and clinical outcomes has yet to be reported.

Objective

To determine the association of Erich arch bars, 4-point fixation, and bone-supported arch bars in maxillomandibular fixation with hospital charges and clinical outcomes.

Design, Setting, and Participants

This historical cohort included 93 patients with mandible fracture who underwent maxillomandibular fixation from January 1, 2005, to June 30, 2015, at a tertiary care center. Statistical analysis was conducted from October 4, 2015, to September 8, 2017.

Main Outcomes and Measures

Charge analysis from an institutional perspective, operative time, necessity for a secondary procedure, and postoperative complications.

Results

Of the 93 patients in the study (18 women and 75 men; median age, 28.0 years [interquartile range, 23.0-40.0 years]), 27 (29%) received Erich arch bars, 51 (55%) received 4-point fixation, and 15 (16%) received bone-supported arch bars. The mean operative time for Erich arch bars (98.7 minutes; 95% CI, 89.2-108.2 minutes) was significantly longer than for 4-point fixation (48.8 minutes; 95% CI, 41.8-55.7 minutes) and bone-supported arch bars (55.9 minutes; 95% CI, 43.1-68.6 minutes). A total of 17 patients who received Erich arch bars (63%), 37 patients who received 4-point fixation (72%), and 1 patient who received bone-supported arch bars (7%) needed to return to the operating room for hardware removal. Patients who received Erich arch bars and those who received 4-point fixation had significantly higher odds of requiring a secondary procedure than did patients who received bone-supported arch bars (Erich arch bars: odds ratio, 27.1; 95% CI, 2.7-274.6; and 4-point fixation: odds ratio, 42.8; 95% CI, 4.4-420.7). Mean total operative charges for application of the hardware alone were significantly less for 4-point fixation ($5290; 95% CI, $4846-$5733) and bone-supported arch bars ($6751; 95% CI, $5936-$7566) than for Erich arch bars ($7919; 95% CI, $7311-$8527). When secondary procedure charges were included, the mean total charge for Erich arch bars ($9585; 95% CI, $8927-$10 243) remained significantly more expensive than the mean total for 4-point fixation ($7204; 95% CI, $6724-$7684) and bone-supported arch bars ($6924; 95% CI, $6042-$7807). No clinically meaningful difference in complications between groups was found (Erich arch bars, 3 [11%]; 4-point fixation, 5 [10%]; and bone-supported arch bars, 2 [13%]).

Conclusions and Relevance

Bone-supported arch bars have comparable complication outcomes, operative time for placement, and overall charges when compared with Erich arch bars and 4-point fixation, and have a lower likelihood of requiring removal in an operative setting.

Comparative Evaluation of the Embrasure Wire versus Arch Bar Maxillomandibular Fixation in the Management of Mandibular Fractures: Are Arch Bars Replaceable?

The aim of this prospective study was to appraise the role of embrasure wiring in the treatment of mandibular fractures over the arch bar as adjunctive techniques of maxillomandibular fixation (MMF). This study was conducted on 40 patients who were surgically treated for mandibular fractures with accessory use of MMF (embrasure: group A vs. arch bars: group B). All patients were evaluated for demographic data, etiology, and location of fracture. Characteristically, the complications, including wire injury, infection, and malocclusion, were recorded. The data were analyzed using Student's t -test and chi-square test as appropriate. Statistical significance was set at p  < 0.05). In this study, data from 40 patients were included. In group A (embrasure wiring), time required for placement of MMF was significantly less than (7.85 ± 0.81 minutes) that in group B, and also there was less incidence of wire prick to the operator in group A than in group B ( p  < 0.05). However, in terms of wire prick and malocclusion, no statistically significant difference was noted in groups A and B ( p  > 0.05). Patient treated with embrasure wiring intermaxillary fixation had better outcomes especially in terms of time of placement and less incidence of wire prick injury when compared with arch bar.

Use of patient-reported outcome measures in oral and maxillofacial trauma surgery: a review

In the UK, about one person/100/year sustains a facial injury, so trauma surgery accounts for a considerable part of the caseload in oral and maxillofacial surgery (OMFS). Patient-reported outcome measures (PROM) allow for patient-centred assessment of postoperative outcomes, but to our knowledge, most research in OMFS trauma does not currently include them. To investigate their use, we searched Medline to find relevant studies that reported outcomes from inception in January 1879 to August 2016. Those not in the English language and those that did not report operations were excluded. We retrieved 416 articles, of which 21 met the inclusion criteria (five randomised controlled trials and 16 cohort studies) yielding 16 outcome measures. Most of these had been devised by authors (eight studies), four studies reported use of the Geriatric Oral Health Assessment Index, and three the Nasal Obstruction Symptom Evaluation. Most were used in studies on mandibular surgery (n=13), followed by those on nasal and facial surgery (n=3 each). There is a great heterogeneity in the use of these assessments in OMF trauma. In view of their increasing importance compared with simpler objective measures that may not be relevant to the patients' own perception, more research is needed to establish which of them can be used to measure the QoL of patients treated for OMF trauma.

Erich arch bar versus hanger plate technique for intermaxillary fixation in fracture mandible: A prospective comparative study

Introduction:

Various methods have been described for intermaxillary fixation (IMF) for treatment of faciomaxillary injuries. Many studies have been described to evaluate the efficacy of different methods. Hanger plate method has not been commonly used. The aim of the present study was to compare the advantages and disadvantages of this method over Erich arch bar in mandibular fracture.

Materials and Methods:

Sixty patients of only mandibular fracture presenting to trauma center requiring open reduction and internal fixation under general anesthesia were randomly allocated to Group A and Group B comprising thirty patients in each. Group A included patients who received IMF with Erich arch bar. Group B included patients who received IMF with hanger plate method. The two groups were compared for time duration of intermaxillary procedure, total duration of surgery, oral hygiene score, postoperative occlusion, and complications.

Results:

The average time of intermaxillary procedure, total duration of surgery, and wire prick injuries were more in Group A. Oral hygiene score was significantly better in Group B. Postoperative occlusion was comparable between the two groups. There was screw loosening in four patients in Group B, but none had tooth root injury. The cost of material for IMF was more in Group B.

Conclusion:

IMF with hanger plate method is more safe and efficacious compared to Erich arch bar in the treatment of mandibular fractures.

Evidence-Based Medicine in Facial Trauma

This article provides the reader with a comprehensive review of high-level evidence-based medicine in facial trauma and highlights areas devoid of high-level evidence. The article is organized in the order one might approach a clinical problem: starting with the workup, followed by treatment considerations, operative decisions, and postoperative treatments. Individual injuries are discussed within each section, with an overview of the available high-level clinical evidence. This article not only provides a quick reference for the facial traumatologist, but also allows the reader to identify areas that lack high-level evidence, perhaps motivating future endeavors.

Maxillomandibular Fixation by Plastic Surgeons: Cost Analysis and Utilization of Resources

PURPOSE

Maxillomandibular fixation (MMF) can be performed using various techniques. Two common approaches used are arch bars and bone screws. Arch bars are the gold standard and inexpensive, but often require increased procedure time. Bone screws with wire fixation is a popular alternative, but more expensive than arch bars. The differences in costs of care, complications, and operative times between these 2 techniques are analyzed.

METHODS

A chart review was conducted on patients treated over the last 12 years at our institution. Forty-four patients with CPT code 21453 (closed reduction of mandible fracture with interdental fixation) with an isolated mandible fracture were used in our data collection. The operating room (OR) costs, procedure duration, and complications for these patients were analyzed.

RESULTS

Operative times were significantly shorter for patients treated with bone screws (P < 0.002). The costs for one trip to the OR for either method of fixation did not show any significant differences (P < 0.840). More patients with arch bar fixation (62%) required a second trip to the OR for removal in comparison to those with screw fixation (31%) (P < 0.068). This additional trip to the OR added significant cost. There were no differences in patient complications between these 2 fixation techniques.

CONCLUSIONS

The MMF with bone screws represents an attractive alternative to fixation with arch bars in appropriate scenarios. Screw fixation offers reduced costs, fewer trips to the OR, and decreased operative duration without a difference in complications. Cost savings were noted most significantly in a decreased need for secondary procedures in patients who were treated with MMF screws. Screw fixation offers potential for reducing the costs of care in treating patients with minimally displaced or favorable mandible fractures.

Multidetector CT of Mandibular Fractures, Reductions, and Complications: A Clinically Relevant Primer for the Radiologist

After the nasal bones, the mandible is the second most common site of facial fractures, and mandibular fractures frequently require open reduction. In the trauma injury setting, multidetector computed tomography (CT) has become the cornerstone imaging modality for determining the most appropriate treatment management, fixation method, and surgical approach. Multidetector CT is also used to assess the adequacy of the reduction and evaluate potential complications in the postoperative period. For successful restoration of the mandible's form and function, as well as management of posttraumatic and postoperative complications, reconstructive surgeons are required to have a detailed understanding of mandibular biomechanics, occlusion, and anatomy. To provide added value in the diagnosis, treatment planning, and follow-up of mandibular fractures, radiologists should be aware of these concepts. Knowledge of the techniques commonly used to achieve occlusal and anatomic reduction and of the rationale behind the range of available treatment options for different injury patterns-from isolated and nondisplaced fractures to multisite and comminuted fractures-also is essential. This article focuses on the use of multidetector CT for pre- and postoperative evaluation of mandibular fractures and outlines fundamental concepts of diagnosis and management-beginning with an explanation of common fracture patterns and their biomechanical underpinnings, and followed by a review of the common postoperative appearances of these fractures after semirigid and rigid fixation procedures. Specific considerations regarding fractures in different regions of the tooth-bearing and non-tooth-bearing mandible and the unique issues pertaining to the edentulous atrophic mandible are reviewed, and key features that distinguish major from minor complications are described. (©)RSNA, 2016.

A comparative study of intermaxillary fixation screws and noncompression miniplates in the treatment of mandibular fractures: a prospective clinical study

BACKGROUND

The main goal of treatment of mandibular fractures is to restore normal dental occlusion and promote appropriate bone healing and a normal mouth opening. Recently, there has been a resurgent interest in the use of screws for intermaxillary fixation of mandibular fractures. This study was therefore designed to determine how the clinical outcomes of the use of screws for intermaxillary fixation compare with the use of miniplates in the treatment of mandibular fractures in Nigeria.

OBJECTIVES

The objectives of this study are as follows: 1. To compare the clinical outcomes of the use of 2.0 mm × 9.0 mm screws for intermaxillary fixation with 2.0 mm noncompression miniplates in the treatment of simple unilateral mandibular fractures in Lagos, Nigeria 2. To determine the clinical outcomes in the use of 2.0 mm × 9.0 mm screws for intermaxillary fixation (IMF) and 2.0 mm noncompression miniplates in the treatment of simple unilateral mandibular fractures 3. To compare the complications associated with the use of 2.0 mm × 9.0 mm screws for IMF and 2.0 mm noncompression miniplates in the treatment of mandibular fractures METHODOLOGY: This randomized controlled clinical study was carried out at the Department of Oral and Maxillofacial Surgery of the study institution. Subjects with simple unilateral mandibular fractures who met the inclusion criteria were randomly allocated into the study (intermaxillary fixation screw) and control (miniplate) groups through balloting. Factors assessed and compared during and after the procedures included intraoperative pain, postoperative nerve impairment, postoperative occlusion, limitation of mouth opening, incidence of hardware failure, incidence of infection and non-union. Data was analysed using the Statistical Package for Social Sciences (SPSS) version 20.

RESULTS

A total of 56 subjects participated in the study, with 28 subjects in each group. Majority (91%) of the subjects were male. Road traffic crash was the highest aetiological factor while sport was the least (3.6%). A higher proportion (25.0%) of subjects in the miniplate group had major complications compared with 14.3% in the IMF screw group. There was no statistically significant association between site of mandibular fracture, time elapsed before treatment and complications (p < 0.05). All cases of mandibular fractures healed successfully at 6 weeks.

CONCLUSION

The use of screws for IMF is as effective as 2.0 mm noncompression miniplates in the treatment of simple unilateral mandibular fractures.

Image quality of cone beam computed tomography for evaluation of extremity fractures in the presence of metal hardware: visual grading characteristics analysis

OBJECTIVE

To evaluate image quality and interobserver reliability of a novel cone-beam CT (CBCT) scanner in comparison with plain radiography for assessment of fracture healing in the presence of metal hardware.

METHODS

In this prospective institutional review board-approved Health Insurance Portability and Accountability Act of 1996-complaint study, written informed consent was obtained from 27 patients (10 females and 17 males; mean age 44 years, age range 21-83 years) with either upper or lower extremity fractures, and with metal hardware, who underwent CBCT scans and had a clinical radiograph of the affected part. Images were assessed by two independent observers for quality and interobserver reliability for seven visualization tasks. Visual grading characteristic (VGC) curve analysis determined the differences in image quality between CBCT and plain radiography. Interobserver agreement was calculated using Pearson's correlation coefficient.

RESULTS

VGC results displayed preference of CBCT images to plain radiographs in terms of visualizing (1) cortical and (2) trabecular bones; (3) fracture line; (4) callus formation; (5) bridging ossification; and (6) screw thread-bone interface and its inferiority to plain radiograph in the visualization of (7) large metallic side plate contour with strong interobserver correlation (p-value < 0.05), except for visualizing large metallic side plate contour.

CONCLUSION

For evaluation of fracture healing in the presence of metal hardware, CBCT image quality is preferable to plain radiograph for all visualization tasks, except for large metallic side plate contours. Advances in knowledge: CBCT has the potential to be a good diagnostic alternative to plain radiographs in evaluation of fracture healing in the presence of metal hardware.

Effect of interfragmentary gap on the mechanical behavior of mandibular angle fracture with three fixation designs: A finite element analysis

BACKGROUND

The aim of this study was to simulate stress and strain distribution numerically on a normal mandible under physiological occlusal loadings. The results were compared with those of mandibles that had an angle fracture stabilized with different fixation designs under the same loadings. The amount of displacement at two interfragmentary gaps was also studied.

MATERIALS AND METHODS

A three-dimensional (3D) virtual mandible was reconstructed with an angle fracture that had a fracture gap of either 0.1 or 1 mm. Three types of plate fixation designs were used: Type I, a miniplate was placed across the fracture line following the Champy technique; Type II, two miniplates were used; and Type III, a reconstruction plate was used on the inferior border of the mandible. Loads of 100 and 500 N were applied to the models. The maximum von Mises stress, strain, and displacement were computed using finite element analysis. The results from the control and experimental groups were analyzed and compared.

RESULTS

The results demonstrated that high stresses and strains were distributed to the condylar and angular areas regardless of the loading position. The ratio of the plate/bone average stress ranged from 215% (Type II design) to 848% (Type I design) irrespective of the interfragmentary gap size. With a 1-mm fracture gap, the ratio of the plate/bone stress ranged from 204% (Type II design) to 1130% (Type I design). All strains were well below critical bone strain thresholds. Displacement on the cross-sectional mapping at fracture interface indicated that uneven movement occurred in x, y, and z directions.

CONCLUSIONS

Interfragmentary gaps between 0.1 and 1 mm did not have a substantial effect on the average stress distribution to the fractured bony segments; however, they had a greater effect on the stress distribution to the plates and screws. Type II fixation was the best mechanical design under bite loads. Type I design was the least stable system and had the highest stress distribution and the largest displacement at the fracture site.

Drill-related root injury caused by intraoperative intermaxillary fixation: an analysis of 1067 screw applications

BACKGROUND/AIMS

Intermaxillary fixation is a standard procedure for the treatment of mandibular fractures or in orthognathic surgery. Predrilling for screws poses the risk of accidental tooth root injury, potentially leading to further pathological processes. Limited evidence about accidental tooth injury during intermaxillary fixation is available due to heterogenous study designs. The aim of this study was to evaluate the risk of root trauma using predrilled transgingival fixation screws and the clinical consequences for the affected teeth.

MATERIALS AND METHODS

In this retrospective study, the data of open reduction and internal fixation surgery files with intraoperative application of predrilled intermaxillary fixation screws were analysed. The postoperative radiographic images were evaluated for the occurrence of tooth root injury. Patients diagnosed with root injury were clinically followed up with respect to the dental health for the affected teeth.

RESULTS

A total of 133 radiologically diagnosed tooth root injuries were recorded (12.5% of screws). The median follow-up interval was 16 months (range: 3-77 months). The return rate was 49.5% for all patients. Of these, four of the injured teeth (3%) needed endodontic treatment. No toothache was reported, no tooth was lost, and no negative impact on periodontal health was clinically evident.

CONCLUSION

Intermaxillary fixation with predrilled transgingival screws is a safe way to manage mandibular fractures. The incidence of tooth root injury is not uncommon, but the adverse side effects are rare and the health of the affected teeth is mostly not compromised.

Intermaxillary Fixation Screw Morbidity in Treatment of Mandibular Fractures-A Retrospective Study

PURPOSE

The aim of the present retrospective study was to investigate the morbidity of screws used for intermaxillary fixation (IMF) in the treatment of mandibular fractures. A review of the published data was also performed for a comparison of outcomes. Our hypothesis was that the use of screws for IMF of mandibular fractures would result in minimal morbidity.

MATERIALS AND METHODS

Patients treated for mandibular fractures from 2007 to 2013, using screws for IMF, using the international diagnosis code for mandibular fracture, DS026, were anonymously selected (Department of Oral and Maxillofacial Surgery, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark). The fracture type, radiographic findings, treatment modality, screw type and number, and root damage were recorded. For the outcome comparison, a review of the published data regarding iatrogenic dental root damage caused by screw fixation was performed in May 2015.

RESULTS

A total of 156 patients had undergone IMF with screws. The total number of screws was 793. The incidence of root lesions was 0.25% centrally and 0.88% peripherally. The incidence of screw loss was 0.13% and that of screw loosening was 1.89%. In the review, 737 related reports were identified in a search of PubMed and the Cochrane Library. Of these, 25 were considered suitable for inclusion. A lack of valid evidence resulted in a descriptive analysis, because a meta-analysis of the data was not possible.

CONCLUSIONS

The results of the present retrospective study have shown that the use of screws is a valid choice for IMF in mandibular fracture treatment with minimal morbidity. The 793 screws used for IMF resulted in a negligible amount of central and peripheral tooth root trauma.

Reporting of Postoperative Pain Management Protocols in Randomized Clinical Trials of Mandibular Fracture Repair: A Systematic Review

IMPORTANCE

The control of pain associated with mandibular fractures is an important treatment outcome that affects function, adherence to treatment regimens, and patient comfort and satisfaction.

OBJECTIVE

To explore the pain management protocols reported in studies of mandibular fractures, including the reporting of quality-of-life measures.

EVIDENCE REVIEW

PubMed/MEDLINE, EMBASE, Cochrane CENTRAL, and clinicaltrials.gov were searched for randomized clinical trials published from 1970 to July 2014. We followed PRISMA reporting standards to assess study eligibility and extract data. Studies of patients older than 16 years who underwent operative mandibular fracture management were included. The primary data collected included the type of analgesic prescribed, associated adverse effects of the analgesic, method of pain assessment, and use of quality-of-life measures. A pain attentiveness score was assigned to studies based on the comprehensiveness of the information reported. Several variables were reviewed to determine the factors that predict reporting of pain-related data. Assessments of risk for bias were performed using the Cochrane Collaboration's domain-based evaluation method.

FINDINGS

The initial search identified 111 articles, of which 38 met inclusion criteria. Among the 38 reviewed articles, there were 38 trials and 1808 unique patients represented. Among the 38 articles, the procedures reported included maxillomandibular fixation only in 6 (16%), open reduction with internal fixation only in 20 (53%), and both in 12 (32%). Specific analgesics prescribed were reported in only 5 of the 38 studies (13%), and 3 of these used a combination of nonsteroidal anti-inflammatory drugs and acetaminophen (paracetamol). Thirteen studies (34%) reported pain assessments and 5 (13%) included quality-of-life measures. Geographic region was the only variable that predicted pain attentiveness, with studies from Europe (3 of 11 studies [27%]) and Asia (6 of 16 studies [38%]) most likely to have a high pain attentiveness score. A low rating was least common in the United States (2 of 5 studies [40%]) (P = .047, Fisher exact test). Most of the studies had unclear (n = 27) or high (n = 6) risks for bias in the key domains assessed.

CONCLUSIONS AND RELEVANCE

Pain management is a neglected outcome in randomized clinical trials of mandibular trauma; most studies did not describe the specific analgesics used. Many randomized clinical trials (13 [34%]) assessed pain levels among patients without providing information about the agents prescribed. The incorporation of validated pain measures and quality-of-life scores in future studies of mandibular trauma would focus attention on this key outcome measure.

A Comparison of Torque Forces Used to Apply Intermaxillary Fixation Screws

PURPOSE

When establishing intermaxillary fixation (IMF) using bone screws, fracture of a screw is a potential complication. This study was conducted to investigate the forces that arise at bone screw insertion and to determine safety margins between torque for manually tightened insertion and torque until breakage for 3 different IMF screw systems, which could ultimately favor the use of 1 IMF screw system based on decreased risk of complications.

MATERIALS AND METHODS

IMF screws were placed into porcine mandibles by 3 oral and maxillofacial surgeons. The porcine mandibles were evaluated for cortical thickness and suitable insertion sites by cone-beam computed tomography. Measurements of torque until failure were performed on predrilled aluminum plates by the primary author. A digital torque screwdriver measured 180 data points per second as continuous data and recorded the measurements.

RESULTS

Measurements indicated clear differences in torsion forces between manually tightened insertions and torque until breakage for all 3 IMF screw systems. No statistical difference in safety margins was found among the IMF screw systems.

CONCLUSIONS

Because no statistical differences in safety margins were found among the IMF screw systems, this study indicates that IMF screw selection should be based on other clinical factors, such as ease of use or economic factors. Future prospective studies are necessary to fully determine evidence-based criteria for IMF screw selection.

Is There Enough Evidence to Regularly Apply Bone Screws for Intermaxillary Fixation in Mandibular Fractures?

PURPOSE

Intermaxillary fixation (IMF) is traditionally achieved with arch bars; however, this method has several well-known disadvantages and other techniques, such as bone screws, are available. This study evaluated current evidence regarding these IMF screws (IMFSs) for mandibular trauma and to assess whether this allows a change of treatment protocol for IMF.

MATERIALS AND METHODS

A systematic electronic literature search was conducted in the PubMed, Embase, and Cochrane databases. Titles and abstracts retrieved from the search were screened and evaluated for inclusion and exclusion criteria. The full text of all relevant articles was read and citation lists were checked for any missing references. All randomized controlled trials (RCTs) were subjected to a quality assessment. Included articles were checked for outcome measurements concerning occlusion, operative time, oral hygiene, root trauma, wire-stick injuries, and mucosa overgrowth.

RESULTS

Twenty-two articles (17 case series, 4 RCTs, and 1 cohort study) were included. None of the RCTs scored high methodologic results in the quality assessment. The results suggest IMFSs have similar malocclusion rates as arch bars, fewer wire-stick injuries, improved oral hygiene, and shorter operative time. Root damage is less likely to occur with self-drilling screws and seldom requires treatment.

CONCLUSIONS

Although the methodologic quality of the included studies is poor, self-drilling IMFSs are recommended for temporary per-operative IMF of noncomminuted mandibular fractures. More high-quality studies are required to allow an evidence-based change of protocol.