1
|
Oksa M, Haapanen A, Kannari L, Furuholm J, Snäll J. Surgical treatment of clinically infected mandibular fractures. Oral Maxillofac Surg 2024; 28:839-847. [PMID: 38286958 PMCID: PMC11144672 DOI: 10.1007/s10006-024-01213-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 01/18/2024] [Indexed: 01/31/2024]
Abstract
PURPOSE To clarify reasons for infections, surgical techniques, and occurrence of postoperative surgical site complications in infected mandibular fractures. METHODS Patients with clinically infected mandibular fracture of the dentate part without preceding surgery were studied retrospectively. Clinical infection was defined to occur if pus, abscess, or a fistula in the fracture area was present. Patient-, fracture-, and surgery-related variables were evaluated, and predictors for postoperative complications were analysed. RESULTS Of 908 patients with surgically treated fracture in the dentate part of the mandible, 41 had infected fracture at the time of surgery (4.5%). Of these patients, 46.3% were alcohol or drug abusers. Median delay from injury to surgery was 9 days. Patient-related factors were the most common cause for delayed surgery (n = 30, 73.2%), followed by missed diagnosis by a health care professional (n = 8, 19.5%). Twenty-two fractures were treated via extraoral approach (53.7%) and the remaining 19 intraorally (46.3%). Postoperative surgical site complications were found in 13 patients (31.7%), with recurrent surgical site infections predominating. Notable differences between total complication rates between intraoral and extraoral approaches were not detected. Secondary osteosynthesis for non-union was conducted for one patient treated intraorally. CONCLUSIONS Postoperative surgical site complications are common after treatment of infected mandibular fractures, and these occur despite the chosen surgical approach. Infected mandibular fractures heal mainly without bone grafting, and non-union is a rare complication. Due to the high complication rate, careful perioperative and postoperative care is required for these patients.
Collapse
Affiliation(s)
- Marko Oksa
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Haartmaninkatu 1, FI-00290, Helsinki, Finland.
- Helsinki University Hospital, Haartmaninkatu 1A, FI-00029, Helsinki, Finland.
| | - Aleksi Haapanen
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Haartmaninkatu 1, FI-00290, Helsinki, Finland
- Helsinki University Hospital, Haartmaninkatu 1A, FI-00029, Helsinki, Finland
| | - Leena Kannari
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Haartmaninkatu 1, FI-00290, Helsinki, Finland
- Helsinki University Hospital, Haartmaninkatu 1A, FI-00029, Helsinki, Finland
| | - Jussi Furuholm
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Haartmaninkatu 1, FI-00290, Helsinki, Finland
- Helsinki University Hospital, Haartmaninkatu 1A, FI-00029, Helsinki, Finland
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Haartmaninkatu 1, FI-00290, Helsinki, Finland
- Helsinki University Hospital, Haartmaninkatu 1A, FI-00029, Helsinki, Finland
| |
Collapse
|
2
|
Wang TT, Lee CC, Gross AJ, Hajibandeh JT, Peacock ZS. Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures? J Oral Maxillofac Surg 2024; 82:554-562. [PMID: 38403271 DOI: 10.1016/j.joms.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives. PURPOSE To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures. METHODS This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded. PREDICTOR The primary predictor variable was primary payer (public, private, self-pay, and other/no charge). OUTCOME VARIABLE The primary outcome variable was hospital admission (yes/no). COVARIATES Covariates included patient-, medical/injury-, and hospital-related variables. ANALYSES Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant. RESULTS The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission. CONCLUSIONS In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.
Collapse
Affiliation(s)
- Tim T Wang
- Resident, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Clinical Fellow, Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA
| | - Cameron C Lee
- Head and Neck Oncology Fellow, University of Maryland Medical Center, Baltimore, MD; Clinical Research Fellow, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Andrew J Gross
- Pediatric Craniomaxillofacial Clinical and Research Fellow, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Jeffrey T Hajibandeh
- Instructor and Director of Quality & Safety, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA
| | - Zachary S Peacock
- Chair, Division of Oral and Maxillofacial Surgery, Massachusetts General Hospital and Department of Oral and Maxillofacial Surgery, Harvard School of Dental Medicine, Boston, MA.
| |
Collapse
|
3
|
Oksa M, Haapanen A, Marttila E, Furuholm J, Snäll J. Postoperative wound dehiscence in mandibular fractures. Acta Odontol Scand 2023; 81:555-561. [PMID: 37171859 DOI: 10.1080/00016357.2023.2211156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
OBJECTIVE To clarify the occurrence and causes of non-infection-related surgical wound dehiscence (SWD) in intraorally treated mandibular fractures. MATERIAL AND METHODS Patients with one or two fractures of the dentate part of the mandible treated surgically via an intraoral approach were included in this retrospective study. The primary outcome variable was SWD. Associations between patient-, fracture- and surgery-related variables and SWD were evaluated. RESULTS Altogether 232 patients with 270 mandibular angle, body, symphysis and/or parasymphysis fractures were included in the analysis. In all, 22 SWDs were detected. These occurred in 9.5% of patients and in 8.1% of fractures. Surgery performed at night-time showed a significantly higher SWD rate than daytime surgeries (p = .012). Additionally, a significantly greater SWD rate was found among smokers (p = .041). Other studied variables remained statistically non-significant for SWD. In a multivariate analysis, night-time was the only significant independent variable with an odds ratio of 3.297 (95% CI 1.238 - 8.780, p = .017) for SWD. CONCLUSION The approach or closure technique used and the fracture type had only a minor effect on non-infection-related SWD in patients with mandibular fractures. To avoid SWDs, mandibular fracture surgeries should be conducted during the daytime with adequate support from an experienced surgeon.
Collapse
Affiliation(s)
- Marko Oksa
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland, and Helsinki University Hospital, Helsinki, Finland
| | - Aleksi Haapanen
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland, and Helsinki University Hospital, Helsinki, Finland
| | - Emilia Marttila
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland, and Helsinki University Hospital, Helsinki, Finland
| | - Jussi Furuholm
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland, and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland, and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
4
|
Hughes D, Ng SM, Smyth D, Patel H, Kent S, Henry A, Blore C, Dawoud B, Kumar D, Jefferies C, Kyzas P, Collaborators MTR. Emergency versus semi-elective management of mandible fractures: a Maxillofacial Trainee Research Collaborative (MTReC) study. Ann R Coll Surg Engl 2023; 105:461-468. [PMID: 35904336 PMCID: PMC10149241 DOI: 10.1308/rcsann.2022.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures. METHODS A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications. RESULTS Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030). CONCLUSION Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.
Collapse
Affiliation(s)
| | - SM Ng
- Kings College Hospital, UK
| | | | | | - S Kent
- University Hospital of Wales, UK
| | - A Henry
- Cwm Taf Morgannwg University Health Board, Merthyr Tydfil, UK
| | - C Blore
- University Hospitals of North Midlands NHS Trust, UK
| | | | - D Kumar
- Liverpool Medical School, UK
| | | | - P Kyzas
- East Lancashire Hospitals NHS Trust, UK
| | | |
Collapse
|
5
|
Early Outcomes and Risk Factors in Orthognathic Surgery for Mandibular and Maxillary Hypo- and Hyperplasia: A 13-Year Analysis of a Multi-Institutional Database. J Clin Med 2023; 12:jcm12041444. [PMID: 36835979 PMCID: PMC9965345 DOI: 10.3390/jcm12041444] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/29/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Orthognathic surgery (OS) is a frequently performed procedure for the correction of dentofacial deformities and malocclusion. Research on OS is mostly limited to single-surgeon experience or single-institutional reports. We, therefore, retrospectively analyzed a multi-institutional database to investigate outcomes of OS and identify risk factors for peri- and postoperative complications. METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2020) to identify patients who underwent OS for mandibular and maxillary hypo- and hyperplasia. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. We also evaluated risk factors for complications. RESULTS The study population included 674 patients, 48% of whom underwent single jaw surgery, 40% double jaw surgery, and 5.5% triple jaw surgery. The average age was 29 ± 11 years, with an equal gender distribution (females: n = 336; 50%, males: n = 338; 50%). Adverse events were relatively rare, with a total of 29 (4.3%) complications reported. The most common surgical complication was superficial incisional infection (n = 14; 2.1%). While the multivariable analysis revealed isolated single lower jaw surgery (p = 0.03) to be independently associated with surgical complication occurrence, it also identified an association between the outpatient setting and the frequency of surgical complications (p = 0.03) and readmissions (p = 0.02). In addition, Asian ethnicity was identified as a risk factor for bleeding (p = 0.003) and readmission (p = 0.0009). CONCLUSION Based on the information recorded by the ACS-NSQIP database, our analysis underscored the positive (short-term) safety profile of OS. We found OS of the mandible to be associated with higher complication rates. The calculated risk role of OS in the outpatient setting warrants further investigation. A significant correlation between Asian OS patients and postoperative adverse events was found. Implementation of these novel risk factors into the surgical workflow may help facial surgeons refine their patient selection and improve patient outcomes. Future studies are needed to investigate the causal relationships of the observed statistical correlations.
Collapse
|
6
|
Pitak-Arnnop P, Tangmanee C, Subbalekha K, Sirintawat N, Urwannachotima N, Auychai P, Messer-Peti R, Meningaud JP, Neff A. Factors associated with complications of submental intubation in 339 patients with facial fractures: A German retrospective cohort study. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2022; 124:101332. [PMID: 36400390 DOI: 10.1016/j.jormas.2022.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/27/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE For nearly four decades, submental intubation (SI) has been introduced and employed to avoid tracheostomy in facial trauma cases where nasal/oral intubation is infeasible or associated with possible risks. The purposes of this study were to estimate the frequency and to identify variables associated with complications of SI (CSI). METHODS The authors organised a retrospective cohort study and enrolled a group of patients with facial trauma and SI during a seven-year interval at two German level one trauma centres where SI has routinely been used in complex facial trauma cases. The predictor variables included demographic, medical, dental, fracture-related, operative, and postoperative parameters. The outcome variable was CSI. We used descriptive, bivariate, and multivariate analyses at the 0.05 significant level. RESULTS The sample included 339 patients (24.5% females, 9.4% had complications) with an average age of 58.2 ± 12.0 years (range, 17-89). Bivariate analyses revealed nine significant variables. However, forward stepwise multiple logistic regression modelling identified three variables statistically associated with CSI: smoking (OR, 691.8; 95% CI, 75.9 to 6303.9; P < 0.0001; number needed to harm [NNH], 6), moderate to high gingival inflammation (OR, 786.7; 95% CI, 66 to 9378.9; P = 0.002; NNH, 12), and postoperative use of chlorhexidine mouthwash (OR, 0.03; 95% CI, 0.001 to 0.77; P = 0.0003; number needed to treat [NNT], 2). CONCLUSIONS smokers and subjects with gingivitis were more likely to experience CSI. Postoperative chlorhexidine rinsing was the potentially modifiable, albeit low-OR, factor. These findings could help to draw an effective guideline against the CSI.
Collapse
|
7
|
Lee CC, Wang TT, Gandotra S, Hajibandeh JT, Peacock ZS. Interfacility Emergency Department Transfer for Mandibular Fractures in the United States. J Oral Maxillofac Surg 2022; 80:1757-1768. [DOI: 10.1016/j.joms.2022.07.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 07/21/2022] [Accepted: 07/27/2022] [Indexed: 11/30/2022]
|
8
|
Oksa M, Haapanen A, Marttila E, Snäll J. Simple dentate area fractures of the mandible - can we prevent postoperative infections? Acta Odontol Scand 2022; 80:494-500. [PMID: 35130467 DOI: 10.1080/00016357.2022.2036812] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To evaluate the occurrence of surgical site infections and predisposing factors for these in simple mandibular fractures. MATERIAL AND METHODS A retrospective study of patients with fractures of the dentate part of the mandible included patients with intraorally treated simple fractures of the mandibular body, symphysis, and parasymphysis. The primary outcome variable was postoperative surgical site infection. Use of antibiotics, injury mechanism, fracture and surgery-related explanatory variables, patient-related variables and level of oral hygiene according to the modified Total Dental Index were evaluated. RESULTS Of 254 patients with mandibular fractures, 107 were included in the final analysis. The infection group consisted of 18 patients (16.8%). Despite the high infection occurrence, significant differences were not found between antibiotic use or other studied variables and infection occurrence. Infections occurred mainly in patients without any specific explanatory factor for infection. CONCLUSION The notably high occurrence of surgical site infections despite antibiotic use after simple mandibular fracture surgery highlights the importance of perioperative tissue handling and local oral circumstances. It is also necessary to consider whether we generally accept the high risk of infection associated with the intraorally treated simple mandibular fractures.
Collapse
Affiliation(s)
- Marko Oksa
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Aleksi Haapanen
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Emilia Marttila
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|