Evidence-Based Medicine: Mandible Fractures

Characteristics, Treatment, and Prognosis of Pediatric Symphyseal/Parasymphyseal-Condylar Fractures

BACKGROUND

Pediatric condylar fractures combined with symphyseal or parasymphyseal fractures are common but challenging to manage. The authors present fracture characteristics, propose a treatment algorithm, and evaluate the treatment prognosis of pediatric symphyseal/parasymphyseal-condylar fractures.

METHODS

A retrospective review was conducted on pediatric patients who underwent treatment for symphyseal/parasymphyseal-condylar fractures in a trauma center between January of 2006 and January of 2021. Demographic and fracture characteristics were recorded. Complications and functional evaluations, including maximum interincisal opening, Helkimo anamnestic index, and clinical dysfunction index, were assessed after at least 1 year of follow-up.

RESULTS

After screening, 104 participants met the inclusion criteria. Among them, 50.96% received open reduction and internal fixation for symphyseal/parasymphyseal fractures and closed treatment for condylar fractures, 45.19% were treated by liquid diet and functional exercise, and the remaining 3.85% with severe malocclusion were treated with the assistance of orthodontic appliances. During follow-up, the average maximum interincisal opening of the patients increased from 17 ± 6.29 mm to 41.64 ± 6.33 mm. No subjective symptoms were observed in 86.54% of the patients and 79.81% showed no or mild clinical symptoms. Except for 1 patient who developed temporomandibular joint ankylosis, no other severe complication was reported. Postfracture remodeling of the nonfractured condyle was noted in 3 cases.

CONCLUSIONS

Pediatric symphyseal/parasymphyseal-condylar fractures present unique biomechanical and anatomic challenges that require special consideration during management. In this study, satisfactory functional prognosis was achieved following implementation of the treatment algorithm.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

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

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

Complications of Mandibular Fracture Repair

Mandible fracture management has evolved dramatically. Therefore, the variety of surgical complications associated with mandibular fractures, and their incidences, have continued to change as well. This article aims to assess the most common and most concerning complications that can occur secondary to management of mandibular fractures by examining categories of complication types. This article also explores factors and techniques associated with reduced rates of complications as well as the management of complications.

Trends in mandibular fractures in the USA: A 20-year retrospective analysis

BACKGROUND/AIM

The mandible is one of the most fractured bones in the maxillofacial region. This study analyzes trends in mandibular fracture patterns, demographics, and mechanisms since the early 2000s.

MATERIAL AND METHODS

Mandibular fractures were reviewed from the 2007, 2011, and 2017 National Trauma Data Bank including 13,142, 17,057, and 20,391 patients by year, respectively. This database contains hundreds of thousands of patients annually and represents the largest trauma registry in the United States. Variables included number of fractures, sex, age, injury mechanism, and fracture location. Mechanism of injury included assault, motor vehicle crash, fall, motorcycle, bicycle, pedestrian, and firearm. Anatomic locations based on ICD-9/10 codes included symphysis, ramus, condyle, condylar process, body, angle, and coronoid process. Frequencies were compared using Chi-square tests of homogeneity with effect sizes estimated using Cramer's V.

RESULTS

Mandibular fractures represent 2%-2.5% of all traumas reported in the database from 2001 to 2017. The proportion of patients sustaining a single reported mandibular fracture decreased from 82% in 2007 to 63% in 2017. Males consistently experienced 78%-80% of fractures. Eighteen to 54-year-olds experienced the largest percentages of fractures throughout the 21st century, while median age of fracture shifted from 28 to 32 between 2007 and 2017. The most common fracture mechanisms were assault (42% [2001-2005]-37% [2017]), motor vehicle crash (31%-22%) followed by falls (15%-20%). From 2001-2005 to 2017, a decrease was observed in assaults (-5%) and motor vehicle crash (-9%) and an increase in falls (+5%), particularly among elderly females. The mandibular body, condyle, angle, and symphysis represent approximately two-thirds of all fractures without a consistent temporal trend among them.

CONCLUSIONS

The temporal trends observed can be linked to shifting age demographics nationally that may aid clinicians in diagnosis and inform public safety policies aimed at reducing these injuries, particularly among the growing elderly population.

Three-Dimensional-Printed Splint for Use in Pediatric Mandibular Fracture

Mandibular fractures are the most common type, accounting for about 71% of facial fractures in children. The mandible is the only movable bone in the craniomaxillofacial region. The injury of the mandible has a serious impact on the functions of children's mouth opening, chewing, pronunciation, and occlusion. Therefore, the treatment of children's mandibular fractures is particularly important. Because of the characteristics of children with permanent tooth germ blocking and strong skeletal development, the treatment methods of adults cannot simply be used in children with mandibular fractures. Here, we demonstrate the simple, reliable method using 3-dimensional-printing splint for stability of the fracture segments in pediatric patients.

Facial Fractures Have Similar Outcomes When Managed by Either Otolaryngology or Plastic Surgery: Encounters From a Single Level I Trauma Center

Study Design:

Retrospective cohort.

Objective:

Traumatic facial fractures (FFs) often require specialty consultation with Plastic Surgery (PS) or Otolaryngology (ENT); however, referral patterns are often non-standardized and institution specific. Therefore, we sought to compare management patterns and outcomes between PS and ENT, hypothesizing no difference in operative rates, complications, or mortality.

Methods:

We performed a retrospective analysis of patients with FFs at a single Level I trauma center from 2014 to 2017. Patients were compared by consulting service: PS vs. ENT. Chi-square and Mann-Whitney-U tests were performed.

Results:

Of the 755 patients with FFs, 378 were consulted by PS and 377 by ENT. There was no difference in demographic data ( P > 0.05). Patients managed by ENT received a longer mean course of antibiotics (9.4 vs 7.0 days, P = 0.008) and had a lower rate of open reduction internal fixation (ORIF) (9.8% vs. 15.3%, P = 0.017), compared to PS patients. No difference was observed in overall operative rate (15.1% vs. 19.8%), use of computed tomography (CT) imaging (99% vs. 99%), time to surgery (65 vs. 55 hours, P = 0.198), length of stay (LOS) (4 vs. 4 days), 30-day complication rate (10.6% vs. 7.1%), or mortality (4.5% vs. 2.6%) (all P > 0.05).

Conclusion:

Our study demonstrated similar baseline characteristics, operative rates, complications, and mortality between FFs patients who had consultation by ENT and PS. This supports the practice of allowing both ENT and PS to care for trauma FFs patients, as there appears to be similar standardized care and outcomes. Future studies are needed to evaluate the generalizability of our findings.

Radiological investigation of acute mandibular injury

This article focuses on the different imaging modalities used to evaluate acute mandibular fractures and explores important concepts relating to their diagnosis, investigation, and treatment. Significant focus will be given to exploring general management principles, considerations regarding first-line imaging, and recent technological advancement. Computed tomography (CT) is the preferred method when attempting to identify acute mandibular fractures, particularly in trauma patients, and has very high specificity and sensitivity. Multidetector CT now represents the standard of care, enabling fast scan times, reduced artifact, accurate reconstructed views, and three-dimensional (3D) reconstructions. Cone-beam CT is a newer advanced imaging modality that is increasingly being used worldwide, particularly in the ambulatory and intraoperative setting. It produces high-resolution images with submillimeter isotropic voxels, 3D and multiplanar reconstruction, and low radiation dose, however is less widely available and more expensive. Ultrasound is a valuable method in identifying a fracture in unstable patients, but is limited in its ability to detect nondisplaced fractures. Magnetic resonance imaging is useful in determining the presence of soft-tissue injury. CT angiography is invaluable in the assessment of potential vascular injury in condylar fracture dislocations.

THE RELATIONSHIP OF CLINICAL AND MORPHOLOGICAL DATA IN COMMINUTED FRACTURES OF THE LOWER JAW

OBJECTIVE

The aim is to establish the relationship between some clinical, physiological and morphological parameters in patients with the consequences of an acute injury considering the features of pathological and reparative changes in the bone fragments of the lower jaw formed during a fracture using clinical and morphological methods.

PATIENTS AND METHODS

Materials and methods: The material of the study was bone fragments of the lower jaw, removed during osteosynthesis operations in 20 patients with traumatic comminuted fractures. Also, the material of the study was the data obtained during the examination of the above patients. Morphological parameters characterizing the state of the fragments tissues removed during surgical treatment of fractures of the lower jaw and clinical parameters characterizing the patient's condition in cases of traumatic fractures of the lower jaw treatment were identified for frequency and correlation analysis. Different of frequency of individual indicators' gradations cases was determined by the χ-square test, correlations between parameters (correlations of pairs of parameters "clinic - morphology", "clinical and laboratory data - morphology") - by calculating the Pearson association coefficient.

RESULTS

Results: The main pathological and reparative changes are determined in the bone fragments of the lower jaw after a traumatic fracture: osteomedullary ischemic necrosis (traumatic bone infarction), nonspecific productive inflammation, endosteal and periosteal bone regenerates. The severity and frequency of pathological and reparative changes in the bone fragments of the lower jaw vary, leading to various correlations between clinical and morphological indicators of the fragment tissues conditions. Reliable correlations were established between individual clinical and morphological indicators of the state of bone fragments corresponding to the values of the association coefficient in the range of 0.3-0.7, in particular: in the pair "age of the patient" - "endosteal regenerates" - the dependence is negative, of medium strength, significant (p<0.05); in the pair "age of the patient" - "periosteal regenerates" - the dependence is negative, of medium strength, significant (p<0.05); in the pair "fragment surface area" - "osteonecrosis" - the relationship is negative, weak, significant with the probability of error in assessing the value |ra| p<0.1; in the pair "locus of a fracture in the lower jaw" - "type of inflammation in the bone marrow" - the dependence is positive, of medium strength, highly reliable (p<0.01).

CONCLUSION

Conclusions: A comprehensive clinical and morphological examination made it possible to calculate quantitative data that characterize the frequency parameters of the occur¬rence of certain pathological changes in the bone fragments of the lower jaw after a fracture and the features of individual clinical and morphological parameters conjugation in patients with the consequences of a mechanical jaw injury. The obtained data on the correlation dependences of the type "clinic - morphology" can be used to predict the severity of morphological parameters according to the known values of clinical parameters in patients with the consequences of mandibular fractures.

An Unusual Case of Ludwig's Angina Following Mandibular Fracture

The mandible is the most commonly fractured bone in the maxillofacial region following trauma. Severe infections are rare, and so we highlight an unusual presentation of Ludwig’s angina following a late presentation of a mandibular fracture in a 68-year-old gentleman with significant medical co-morbidities. The recovery process was prolonged and involved multi-disciplinary input. This case makes a recommendation for early recognition of mandibular fractures, antibiotic therapy where appropriate, and hypervigilance when caring for patients with systemic illnesses.

Minimally Invasive "Trocar-Free" Approach for Rear Mandibular Fractures Management

ABSTRACT

The request of minimally invasive surgery is progressively expanding the indications of endoscopically assisted intraoral access for mandibular traumas. The aim of our study is to assess how much the use of the angled drill may affect the outcome of patients treated for rear mandibular fracture.In our retrospective case-control trial we enrolled 36 patients with mandibular rear fractures treated through endoscopically assisted intraoral access. Eighteen patients were treated by using an angled drill "trocar free," and 18 treated by linear drills placed through trocars. Surgical times, hospitalization times (HT), and major complications rate were compared between the 2 groups.Group 1 showed a significant reduction in HT (1.72 versus 2.22 days, P = 0.024) and an increase in the surgical times (3.0 versus 2.53 hours, P = 0.019). Significant reduction of total amount of complication was seen in group 1 versus group 2 (P = 0.007).The "trocar free" approach allowed by angled drills, in our hands, greatly reduces the invasiveness of the surgery resulting in a significant reduction in HT and smaller share of vascular-nervous sequelae. Our results suggest the "trocar free" approach as a valuable choice when indicated for the treatment of rear mandibular fractures.

Patterns of pediatric cervical spine fractures in association with mandibular and facial fractures

OBJECTIVES

To determine the incidence, demographics, and outcomes of concurrent cervical spine (C-spine) fractures in pediatric facial trauma.

METHODS

The Kids' Inpatient Database (KID) from the 2016 Healthcare Cost Utilization Project (HCUP) was queried for various facial fractures using International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes. Mandible fractures were further subdivided into fracture site. Patients aged 0-18 were included, and rates of C-spine fracture were analyzed with regards to demographic factors, length of stay, total charges, mortality rate, hospital characteristics, and concurrent facial fractures.

RESULTS

Of 5568 patients included, 4.18% presented with C-spine fracture. Children with C-spine fractures were significantly older (15.02 vs 12.76 years, p < 0.001) and length of stay was significantly longer (11.33 vs 6.44 days, p < 0.001). There was no difference in rate of C-spine fracture when stratified by gender, time of week/year, hospital location/type, or facial fracture other than subcondylar fractures. Subcondylar fractures were positively associated with C-spine fractures (OR 2.08, p = 0.002). C-spine fractures were associated with significantly higher mortality, length of stay, rate of tracheostomy, transfer out of index hospital, and total hospital charges.

CONCLUSIONS

A significant association exists between subcondylar mandible and C-spine fractures. Awareness of this information is vital for clinicians who manage pediatric facial trauma and alerts them to the need to rule out C-spine fractures in this group as these patients have significantly higher lengths of stay, total mean hospital costs, mortality and tracheostomy rates.

Patient Race and Insurance Status Do Not Impact the Treatment of Simple Mandibular Fractures

INTRODUCTION

Health-care disparities have been reported throughout medical literature for decades. While blatant explicit bias is not prevalent, a substantial body of research has been published suggesting that systemic biases related to sex, race, income, and insurance status likely exist. To our knowledge, no study has assessed the impact of patient race and insurance status on clinical decision-making in facial fracture repair in the United States. Thus, the objective of this project was to assess if race and insurance status impacted whether patients obtained open or closed treatment of simple mandibular fractures.

METHODS

Patients who had either open or closed treatment of mandibular fractures were extracted from the 2012 and 2013 National Inpatient Sample and analyzed. Patients who had a length of stay longer than 3 days or died during their inpatient stay were excluded. These exclusion criteria were used to control for patients with polytrauma as well as complicated fractures. Univariate analysis was undertaken to elucidate different variable associations with the type of reduction performed. All covariates were then entered into a multivariable logistic regression model to test the variables simultaneously.

RESULTS

Patients with simple condylar, alveolar border, and closed mandibular fractures were more likely to undergo closed reduction (CR) on univariate analysis, as were patients with female gender and a fall mechanism (P value < .05). African Americans, Hispanics, and patients without insurance were more likely to undergo open reduction on univariate analysis (P value < .05). Multivariate analysis demonstrated that patients with simple condylar, subcondylar, alveolar border, or closed mandibular fractures were more likely to undergo a CR, as were patients with female gender and a firearm or fall mechanism (P < .05). However, neither race nor insurance status demonstrated a statistically significant association with closed or open reduction.

CONCLUSION

Anatomic location and mechanism of injury were the variables found to be significantly associated with patients undergoing open reduction versus CR of simple mandibular fractures-not race or insurance status.

Writing an Evidence-based Article in Plastic Surgery: Translating Research into High-quality Care

Evidence-based medicine (EBM) is a triad that integrates the physician's medical expertise and the patient's individual characteristics with the best available scientific evidence. As patients become more active in the clinical decision-making process, the application of evidence-based practice in the field of plastic surgery is more critical now than ever. As a field that is recognized by its innovation, plastic surgeons must understand the various aspects of EBM to enhance and keep the field at the top of medical discovery. Many initiatives have been implemented to guide researchers in the collection, analysis, and distribution of high-quality evidence. In particular, Plastic and Reconstructive Surgery introduced a new EBM series to provide plastic surgeons with the appropriate resources to generate and integrate high-quality evidence into their practices. As a part of this initiative, this article will assist researchers in producing an evidence-based article that is well-written, relevant, and impactful to incorporate evidence-based practice into the specialty.

Resorbable Implants for Mandibular Fracture Fixation: A Systematic Review and Meta-Analysis

Mandibular fractures in adults commonly require rigid fixation to ensure proper occlusion while minimizing infection risks. Numerous centers have assessed the efficacy of resorbable materials as a potential alternative to metallic plates. The purpose of the current systematic review and meta-analysis is to shed light on overall outcomes for resorbable implants and to compare these results to those for metallic counterparts.

The Quality of Life of Patients with Surgically Treated Mandibular Fractures and the Relationship of the Posttraumatic Pain and Trismus with the Postoperative Complications: A Prospective Study

Background and objectives: Due to the fact that the mandible is the only movable bone in the face, it is often exposed to the influence of external forces. The incidence of trismus and posttraumatic pain in unilateral mandibular corpus fractures may be related to the occurrence of complications. There is a decrease in the quality of life of these patients. The aim was to study the relationship of the preoperative pain and trismus with the incidence of complications, as well as to investigate the quality of life. Materials and Methods: A prospective study on 60 patients with isolated mandibular fractures was performed, with a follow-up period of six months. The level of preoperative pain was measured on a 0–10 scale, while the mouth opening was measured with a caliper. All patients were treated surgically on the third day after the fracture. The University of Washington Quality of Life (UW-QOL v4) questionnaire was used to analyze the quality of life. Results: The most common types of complications were the occlusal derangement and facial asymmetry. The majority of complications were treated with counseling and physical therapy. The degree of preoperative pain was significantly positively related to the onset of complications (r_s = 0.782, p = 0.004). The interincisal distance showed a significant inverse relation with the incidence of complications (r_s = −0.722, p < 0.001). The patients regarded the pain, appearance and mood issues as the most important issues during the first postoperative month. Conclusions: The degree of inflammatory symptoms may be positively related to the onset of complications occurring after the rigid fixation of mandibular fractures. The postoperative health-related and overall quality of life was unsatisfactory in nearly half of the patients.

Cone Beam Computed Tomography

In the last several decades, the need for 3D images in dentistry have developed. Computerized tomography was first introduced mainly with the advent of implantology, but its use remained limited to a small number of specialists, due to its indications, access and dose radiation. In the late 90's, a new technology using a cone-shaped beam and a reciprocating detector, which rotates around the patient 360 degrees and acquires projected data in a single rotation, namely the cone beam computerized tomography (CBCT), invaded dentistry, making the perception of 3D easily acceptable to dentists and their patients.