Etiology, Treatment, and Complications of Mandibular Fractures

Epidemiological analysis of the facial fractures pattern in relation to motorcycle helmet type: A retrospective study on 282 patients

Most maxillofacial traumas are caused by road traffic collisions and, in particular, by motorcycle accidents. Helmets represent an efficient protective tool in these traumas but they do not provide complete protection. The aim of this study was to perform an epidemiological analysis of facial fractures pattern in relation to the helmet type worn during the accident. The study was a retrospective analysis of 282 patients with a diagnosis of maxillofacial fracture caused by a motorcycle accident. The patients were divided in three groups based on helmet type (Group A: full-face helmet; Group B: modular [half-face] helmet; Group C: open-face helmet). For each group, fractures type and trauma severity, using the Comprehensive Facial Injury (CFI) scale, were recorded. Results showed that isolated midface fractures were strongly related to full-face helmet wearing (p < 0.001), while mandibular fractures and panfacial trauma/combined fractures were negatively correlated (p < 0.001). Mandibular fractures (p < 0.001) and panfacial trauma/combined fractures (p < 0.001) were strongly related to open helmet. Moreover, severe trauma (CFI 8.16) was recorded for open-face helmet wearing. In conclusion, full-face helmet wearing reduced the risk of facial fracture, in particular panfacial trauma/combined fractures, while open-face helmet wearing increased the risk of these fractures.

Influence of COVID-19 pandemic on mandible fracture patterns in a German cranio-maxillofacial trauma center: PreCOVID (2019) versus IntraCOVID (2020)

BACKGROUND/AIMS

The COVID-19 (Coronavirus Disease-2019) pandemic confronted the global healthcare system with a variety of challenges. The pandemic and the associated lockdowns also had an impact on multiple medical disciplines (i.e. delay of surgery, change of hospital admissions). The aim of this study was to analyze the impact of the COVID-19 pandemic on mandible fracture patterns/distributions and circumstances in a German cranio-maxillofacial trauma center.

MATERIALS AND METHODS

This retrospective study compared the mandible fracture patterns of patients in the PreCOVID (PC) era (February 2019-January 2020) with patients in the IntraCOVID (IC) era (February 2020-January 2021). In addition to baseline characteristics, the number/type of mandible fractures, location of the mandible fracture, circumstances leading to mandible fracture, and hospital admissions/treatments were analyzed.

RESULTS

A total of 127 patients was included in this study. In the IC period, the absolute frequencies of mandible fractures decreased (PC = 72 vs. IC = 55). There were minor changes in the mandible fracture locations. An increase of concomitant facial soft tissue injuries (IC = 69.1% vs. PC = 58.3%), as well as higher rates of traumatic tooth loss (IC = 32.7% vs. PC = 22.2%), was observed. Regarding the causes/accidents leading to mandible fractures, there were significant increases in falls and significant decreases in sports accidents as well as interpersonal violence during the IC period. A significant increase in accidents at home and domestic violence during the COVID-19 pandemic, with a simultaneous decrease in weekend and night-time trauma leading to mandible fractures was observed. Furthermore, a significant increase in days from trauma to surgery was recorded.

CONCLUSION

The COVID-19 pandemic had a significant impact on mandibular fracture patterns. The locations and types of mandibular fractures changed slightly. However, significant differences in the circumstances leading to mandible fractures (increased falls, decreased interpersonal violence) were recorded.

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.

Profile of Facial Trauma Victims of Motorcycle Accidents: A Prospective Study

OBJECTIVE

To outline the profile of patients with facial trauma, victims of motorcycle accidents, treated at the Hospital da Restauração, Recife/PE, Brazil, from December 2020 to July 2021.

METHODS

The collection was carried out through questionnaire and analysis of medical records. Data were analyzed descriptively, as well as Pearson's chi-square test or Fisher's exact test.

RESULTS

Among the patients, 88.6% were male, 47.5% were between 18 and 29 years old, and 59.6% lived in rural areas; 72.15% of the victims used the motorcycle for work and 43.52% were working at the time of the accident. Most victims did not have a national motorcycle license (62%) and were not wearing a helmet at the time of the accident (60%), with 37.6% wearing a full-face helmet, 16.5% an open helmet, and 5.9% an articulated full-face helmet. Soft tissue injuries were the most prevalent. Zygomatic complex fractures were the most common facial fractures and were significantly associated with helmet use and type.

CONCLUSIONS

Most victims of motorcycle accidents are young adult men, without a regular driver's license and residing in rural areas. Preventive and educational actions and continuous traffic inspections are necessary to minimize these accidents.

Current Strategies for Treatment of Mandibular Fractures With Plate Osteosynthesis: A European Prospective Study

PURPOSE

The training and preferences of surgeons influence the type of surgical treatment for mandibular fractures. This multicentre prospective study analyzed the current treatment strategies and outcomes for mandibular fractures with open reduction and internal fixation (ORIF).

MATERIAL AND METHODS

This prospective study included patients aged ≥16 years who underwent ORIF for mandibular fractures in 12 European maxillofacial centers. Age, sex, pretrauma dental status, fracture cause, site and type, associated facial fractures, surgical approach, plate number and thickness (≤1.4 or ≥1.5 mm), duration of postoperative maxillomandibular fixation, occlusal and infective complications at 6 weeks and 3 months, and revision surgeries were recorded.

RESULTS

Between May 1, 2021 and April 30, 2022, 425 patients (194 single, 182 double, and 49 triple mandibular fractures) underwent ORIF for 1 or more fractures. Rigid osteosynthesis was performed for 74% of fractures and was significantly associated with displaced ( P =0.01) and comminuted ( P =0.03) fractures and with the number of nonsurgically treated fracture sites ( P =0.002). The angle was the only site associated with nonrigid osteosynthesis ( P <0.001). Malocclusions (5.6%) and infective complications (5.4%) were not associated with osteosynthesis type.

CONCLUSION

Rigid osteosynthesis was the most frequently performed treatment at all fracture sites, except the mandibular angle, and was significantly associated with displaced and comminuted fractures and the number of nonsurgically treated fracture sites. No significant differences were observed regarding postoperative malocclusion or infections among osteosynthesis types.

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.

Patterns of Mandibular Fractures through Human Aggression: A 10-Year Cross-Sectional Cohort Retrospective Study

The World Health Organization considers the victims of interpersonal violence to be a medical priority. In order to provide services at the highest level, we aimed to evaluate the patterns of maxillofacial fractures caused by interpersonal violence, in order to treat, counsel and guide these patients. This retrospective study was conducted in 478 patients with mandibular fractures caused by interpersonal violence over 10 years in a university clinic. The most affected were male patients (95.19%), 20-29 years of age (46.86%), under the influence of alcohol (83.26%) and without education (43.9%). The majority of mandibular fractures were displaced (89.3%) and intraorally open (64.0%). The most frequent location was the mandibular angle (34.84%). The most frequent soft tissue lesions were hematomas (45.04%) and abrasions (34.71%), being associated frequently with closed (p = 0.945/p = 0.237), displaced (p = 0.001/p = 0.002), single angle fractures (p = 0.081/p = 0.222). Educating the population and fighting alcohol consumption would decrease the occurrence of mandibular fractures through aggression. Clinical diagnosis should be made, keeping in mind that the severity of associated soft tissue lesions is directly proportional to the pattern and number of underlying fracture lines.

Frailty, Age, ASA Classification, and BMI on Postoperative Morbidity in Mandibular Fracture ORIF

OBJECTIVE

To assess how traditional, simple markers of health independently affect postoperative morbidity of mandibular fracture open reduction-internal fixations (ORIFs).

STUDY DESIGN

Cohort study.

SETTING

National Surgical Quality Improvement Project (NSQIP) Database.

METHODS

The 2005 to 2017 NSQIP database was queried for patients who underwent mandibular ORIF. To control for the severity of the trauma, an additional "concurrent surgery" variable was created. A modified 5-item frailty index was calculated based on the following: presurgery-dependent functional status, chronic hypertension, diabetes mellitus, history of chronic obstructive pulmonary disease, and history of congestive heart failure.

RESULTS

Among 1806 patients with mandibular ORIFs (mean age 34.8 ± 15.4 years), modified frailty index (mFI) was associated with 30-day medical complications (p < .001), reoperation (p < .001), and readmission (p = .005) on univariate analysis. Increased age was associated with prolonged hospitalization (p < .001) and medical complications (p < .001). The increased American Society of Anesthesiologists (ASA) score was associated with all endpoints (p ≤ .003), while increased body mass index (BMI) was associated with none. On multivariate analysis, only increased ASA was associated with any adverse event (reference: ASA 1; ASA 2, odds ratio [OR]: 2.17 [95% confidence interval, CI: 2.17-3.71], p = .004; ASA 3-4, OR: 3.63 [95% CI: 1.91-6.91], p < .001). Similarly, mFI and BMI were not independently associated with prolonged hospitalization (≥2 days) (p ≥ .015), but 65+ age (reference: 18-49; OR: 2.33 [95% CI: 1.40-3.86], p = .001) and ASA 3 to 4 groups (reference: ASA 1; OR: 3.26 [95% CI: 2.06-5.14], p < .001) were.

CONCLUSION

ASA status and age are more useful modalities than mFI or BMI in predicting poor postoperative morbidity in mandibular ORIF. These simple metrics can assist with managing surgeons' expectations for mandibular ORIF patients.

Pediatric mandibular fractures: Surgical management and outcomes in the deciduous, mixed and permanent dentitions

BACKGROUND/AIM

Mandibular fractures are the most frequent type of pediatric facial traumatic injury, but their treatment remains controversial. The aim of this retrospective study was to analyze the surgical treatment and long-term outcomes of dentate mandibular fractures in children and adolescents.

MATERIAL AND METHODS

Patients with mandibular fractures in the dentate area who were surgically treated in the period from January 1, 2001, to December 31, 2020, were included. The following data were collected: age, gender, cause and mechanism of injury, fracture site and type, associated maxillofacial fractures, the timing of surgical treatment, Facial Injury Severity Scale (FISS) score, surgical approach, number and thickness of plates, hospitalization stay and outcome. Patients were divided into three groups: deciduous (≤6 years, group A), mixed (7-12 years, group B), and permanent (13-18 years, group C) dentitions. Statistical analyses were performed using SPSS software.

RESULTS

During the study 91 patients (male: female ratio, 3.8:1), 4 in group A, 12 in group B, and 75 in group C, with 65 single and 52 double fractures were included. An intraoral approach was used in 87% of patients. In group C, 90% of patients were treated with fixation schemes consistent with those suggested in the literature for adults, versus 75% in groups A and B. Median follow-up time was 20 months. No tooth germ injury or facial asymmetry was observed and only six group C patients had post-operative malocclusions. Hardware removal occurred in 22% of the patients.

CONCLUSIONS

This 20-year retrospective study shows that open reduction and internal fixation of pediatric dentate mandibular fractures caused no tooth germ damage or disturbances of mandibular growth in any dentition stage. Internal fixation schemes were similar to those used for adults, although it was necessary to adapt hardware size and position according to tooth and patient age.

Analysis of the risk factors influencing complications in surgical treatment of mandibular fractures: A retrospective study

The study aim was to identify risk factors associated with complications following open reduction and internal fixation of mandibular fractures. A retrospective cohort study was conducted in patients who were treated for mandibular fractures in a single center between January 2010 and December 2020. Authors classified postoperative complications as overall complications, infections, and reoperations. Factors that may be associated with these complications were grouped as patient, wound, and management variables. Statistical analysis was performed to determine whether these factors influenced complications. Among 175 patients, 125 underwent open reduction and internal fixation. Among patient variables, alcohol consumption was a risk factor for overall complications (p = 0.03) and reoperation (p = 0.02). Among wound variables, the more severe the external wound, the greater the incidence of overall complications (p = 0.001) and infections (p < 0.001). Presence of two or more fracture sites was a risk factor for reoperation (p = 0.038). Among management variables, intraoral and extraoral approaches increased the rates of overall complications, infections, and reoperation. In the multivariate analysis, only intraoral and extraoral approaches were associated with significant risks for overall complications (OR = 5.63, p = 0.017) and infections (OR = 11.53, p = 0.005). Alcohol consumption, external wound severity, multiple fracture site, and incision approach were related to postoperative complications. These findings can help guide surgical decisions and manage patient expectations after surgery.

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.

Treatment of Gunshot-Related Mandibular Fracture with Splint-Guided Reduction: Case Report

Background/Aim: Gunshot injury-related mandibular fractures often have a complex pattern, characterized by comminution, bone loss, and soft-tissue avulsion. The management is difficult and varies between individual cases.

Case Report: A 41-year-old male patient presented with marked swelling and ecchymosis in the left mandibular region. Intraorally, he had a deviated open bite on the left side. A unilateral comminuted mandibular fracture was diagnosed by panoramic radiograph and computed tomography. An acrylic dental splint-guided open reduction and internal fixation, including intermaxillary fixation through brackets and intermaxillary elastics, was planned. No complications were observed throughout the healing period, and healing at the fracture site was satisfactory. The occlusion returned to the preinjury position and was stable.

Conclusions: This case report shows that successful functional and esthetic results can be achieved with a strict patient-specific treatment protocol for a comminuted mandibular fracture due to gunshot injury.

Patterns of Mandibular Fractures in South Australia: Epidemiology, Treatment, and Clinical Outcomes

INTRODUCTION

The mandible is one of the most common facial bones to be injured with great clinical variability across countries caused by assaults, road traffic accidents, and falls.

METHODS

A retrospective review was conducted for adult mandibular fractures from January 2012 to January 2017 at the Royal Adelaide Hospital, Adelaide. Our aim was to describe epidemiological trends of mandibular fractures, differences for sex and age, and clinical outcomes.

RESULTS

Five hundred sixty five adult patients presented with a mandibular fracture with a male predominance (4.5:1). The mean age was 34.2 years with men 11.9 years younger than females (32.0 versus 44.1 years, P < 0.001). Assaults represented 58.2% of cases. A quarter of the cohort reported alcohol use. Assaults commonly resulted in angle and symphyseal fractures, whereas almost all falls and road traffic accident resulted in condylar or coronoid fractures. Young men were 1.9 times more likely to have mandibular fractures compared to women, whereas elderly men were 11.8% less likely (P < 0.001). The most common fracture was the angle (33.6%) and the angle/symphyseal (14.2%). Men were 2.5 times more likely to have surgery. The complication rate was 10.8% and the re-operative rate was 5.0%. Women had a significantly longer admission of 1.6 days compared to men (4.4 versus 2.8 days, P = 0.003).

CONCLUSIONS

Young men are more likely to have mandibular fractures from assaults and have surgery. Young women and elderly females are more likely to have animal and fall-related injuries resulting including in condylar fractures with associated injuries and extended length of stay.

Biomechanical Assessment of the Validity of Sheep as a Preclinical Model for Testing Mandibular Fracture Fixation Devices

Mandibular fracture fixation and reconstruction are usually performed using titanium plates and screws, however, there is a need to improve current fixation techniques. Animal models represent an important step for the testing of new designs and materials. However, the validity of those preclinical models in terms of implant biomechanics remains largely unknown. In this study, we investigate the biomechanics of the sheep mandible as a preclinical model for testing the mechanical strength of fixation devices and the biomechanical environment induced on mandibular fractures. We aimed to assess the comparability of the biomechanical conditions in the sheep mandible as a preclinical model for human applications of fracture fixation devices and empower analyses of the effect of such defined mechanical conditions on bone healing outcome. We developed 3D finite element models of the human and sheep mandibles simulating physiological muscular loads and three different clenching tasks (intercuspal, incisal, and unilateral). Furthermore, we simulated fractures in the human mandibular body, sheep mandibular body, and sheep mandibular diastema fixated with clinically used titanium miniplates and screws. We compared, at the power stroke of mastication, the biomechanical environment (1) in the healthy mandibular body and (2) at the fracture sites, and (3) the mechanical solicitation of the implants as well as the mechanical conditions for bone healing in such cases. In the healthy mandibles, the sheep mandibular body showed lower mechanical strains compared to the human mandibular body. In the fractured mandibles, strains within a fracture gap in sheep were generally not comparable to humans, while similar or lower mechanical solicitation of the fixation devices was found between the human mandibular body fracture and the sheep mandibular diastema fracture scenarios. We, therefore, conclude that the mechanical environments of mandibular fractures in humans and sheep differ and our analyses suggest that the sheep mandibular bone should be carefully re-considered as a model system to study the effect of fixation devices on the healing outcome. In our analyses, the sheep mandibular diastema showed similar mechanical conditions for fracture fixation devices to those in humans.

Application of Inverse Neural Networks for Optimal Pretension of Absorbable Mini Plate and Screw System

Mandibular fractures are common facial lesions typically treated with titanium plate and screw systems; nevertheless, this material is associated with secondary effects. Absorbable material for implants is an alternative to titanium, but there are also problems such as incomplete screw insertion and screw breakage due to high pretension in the screw caused by the insertion torque. The purpose of this paper is to find the optimal screw pretension (SP) in absorbable plate and screw systems by means of artificial neural network (ANN) and its inverse (ANNi). This optimal SP must satisfy a desired maximum von Mises strain (MVMS). For training the ANN, a database was generated by means of a design of experiments (DOE). Each DOE configuration was solved by means of finite element method (FEM) calculations. To obtain the optimal value for (SP) in the mini absorbable screw for fracture fixation, a strategy to invert the ANN is developed. Using the ANN coefficients, a sensitive study was performed to identify the influence of the design parameters in the MVMS. The optimal SP obtained was 14.9742 N. The MVMS condition was satisfied with an error less than 1.1% in comparison with FEM and ANN results. The screw shaft length is the most influencing MVMS parameter.

Epidemiological pattern of maxillofacial fractures in northern China: A retrospective study of 829 cases

This study was performed to examine the epidemiological features of maxillofacial fracture, including the incidence, causes, age and sex distribution, methods of treatment, and prognosis, in a local area.A retrospective study was performed to investigate the epidemiological characteristics of 829 patients with maxillofacial fractures treated in a hospital in northern China from August 2011 to July 2019. Sex, age, etiology, fracture site, and treatment method were obtained from the medical records.The average age of all 829 patients was 36.1 years, and most patients were in the 20- to 29-year age group. The male to female ratio was 3.04:1.00. Traffic accidents were the main cause of the maxillofacial fractures. The mandible was the most commonly fractured bone, and the parasymphysis was the most frequently affected site. Head injury was the most common associated injury. Open surgery with internal fixation was the first-choice treatment for most cases.Traffic accidents were the main cause of maxillofacial fractures, followed by falling. Open surgery with internal fixation was the leading treatment choice. Both functional and esthetic outcomes should be considered in the treatment of maxillofacial fractures.

The Effects of Frontal Trauma on 4 Interforaminal Dental Implants: A 3-Dimensional Finite Element Analysis Comparing Splinted and Unsplinted Implant Configurations

PURPOSE

With increased implant-prosthodontic rehabilitation for mandibular edentulism together with the increased life expectancy and activity of the elderly population, a greater number of implant patients may be at risk of facial trauma. The aim of this 3-dimensional (3D) finite element analysis (FEA) was to evaluate the biomechanical effects of the edentulous mandible (EM) with and without implants exposed to frontal facial trauma including assessment of the fracture risk of different mandibular areas.

MATERIALS AND METHODS

By use of a 3D FEA, our experimental study design comprised 3 different models (model A, EM; model B, EM with 4 unsplinted interforaminal implants; and model C, EM with 4 splinted interforaminal implants) exposed to application of symphyseal frontal trauma of 2 MPa. In 3 defined regions of interest (ROIs) (ROI 1, symphyseal area; ROI 2, mental foraminal area; and ROI 3, condylar neck), the effective stress was measured at predefined sites in the superficial cortical mandibular area. The stress values of all ROIs evaluated were compared within each model (intramodel) as well as between the 3 models (intermodel).

RESULTS

For all models evaluated, a frontal traumatic load generated the highest stress levels in the condylar neck. However, for both models with implants (models B and C), the stress values were reduced significantly (P < .01) in the condylar neck region (ROI 3) but increased significantly (P < .001) in the mental foraminal area (ROI 2) compared with the EM model without implants. For the symphyseal area (ROI 1) evaluated, the unsplinted 4-implant model (model B) presented significantly (P < .001) higher stress values than the splinted implant model (model C) when frontal forces were applied.

CONCLUSIONS

Regardless of splinting or lack of splinting of 4 interforaminal implants, force absorption or transmission may shift the predominant risk factor from the condylar neck to the corpus or foramen mandibulae. However, splinting of 4 interforaminal implants may be beneficial in reducing the risk of bone fracture by providing protection for anterior risk situations.

Profile and costs associated with the use of osteosynthesis materials in victims of traffic accidents

BACKGROUND/AIMS

Facial trauma arising from traffic accidents is one of the most prevalent injuries in urban trauma centers. The aim of this study was to evaluate the frequency, types, and costs associated with osteosynthesis material used in facial fractures of traffic accident victims seen at the Hospital da Restauração, Recife/PE, Brazil, from January to December 2014.

MATERIALS AND METHODS

Data were collected from the medical records of hospitalized patients submitted to surgery under general anesthesia for the treatment of facial fractures during the period. The data were analyzed descriptively by calculating absolute frequencies, percentages, and means. Statistical analysis was performed using SPSS v.21.0.

RESULTS

Among the patients, 73.1% were victims of motorcycle accidents that led to higher costs as they were the most prevalent injuries. Mandibular fractures were the most prevalent injury (53.5%). A total of 477 osteosynthesis materials were used, of which 76.51% were a 2.0-mm plate system, 15.51% were a 1.5-mm plate system, 3.14% were a 2.4-mm plate system, 3.77% titanium meshes, 0.83% lag screws, and 0.2% steel wires. The use of these materials for the treatment of facial fractures resulted in a cost of US $51.285,00 for the Brazilian public health system.

CONCLUSION

The increase in the number of traffic accidents implies significant numbers of victims with facial fractures, as well as considerable costs associated with the use of osteosynthesis materials for public health services.

Direct Three-Dimensional Diagnosis of Ex Vivo Facial Fractures

The aim of the present study is to assess the reliability and accuracy of different 3-dimensional (3D) reconstruction algorithms in detecting undisplaced condylar, zygomatic arc, and orbital rim fractures based on cone-beam computed tomography data set. Twenty sheep heads were used in the present study. Sixty fractured and 60 nonfractured (control) zones were randomly allocated. Three groups consisting of nondisplaced fractures of condyle (CF, n = 20), orbital (OF, n = 20), and zygomatic arc (ZF, n = 20) were created by using a diamond cutting disc. Soft tissues were only dissected and no fractures were generated in the control group (n = 60). The 3D reconstructions were created by using multiplanar reconstruction (MPR), surface rendering (SR), volume rendering (VR), and maximum intensity projection (MIP) algorithms. Final 3D models were examined in Osirix software (Pixmeo SARL, Bernex, Switzerland) by 6 observers. Diagnostic accuracies of each algorithm were statistically compared by receiver operating characteristics (ROC) and area under the ROC curves (AUCs). For the detection of CF, AUC for VR algorithm was found to be statistically larger than that of MIP while AUCs for VR and MIP were larger than those of MPR and SR for OF detection. For the detection of ZF, AUCs for MPR and VR were significantly larger than those of MIP and SR (P < 0.05 for each). Within the limitations of this experimental study, it can be concluded that for maxillofacial surgeons, it is more likely to detect condylar, orbital, and zygomatic fractures by using VR algorithm in 3D reconstruction.

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.

The Diagnosis and Management of Facial Bone Fractures

Appropriate medical care for a patient with a facial fracture can not only optimize aesthetic outcomes but also prevent the potential morbidity and mortality of delayed treatment. In this article, we focus on the clinical presentations, physical examination findings, diagnostic imaging, consultations, and follow-up that patients with facial fractures need related to their emergency department management. Specifically, we address the nuances of evaluating frontal, orbital, nasal, maxillofacial, and mandibular fractures.

Surgical Management of Double/Triple Mandibular Fractures Involving the Condylar Segment: Our Perspective

A series of surgical cases operated in our unit are considered to analyze and evaluate the different techniques and sequencing employed in the surgical management of double/triple mandibular fractures involving a condylar fracture. Deviating from the normal sequence of reducing and fixing the dentate segment first, we addressed the condylar segment first. A combination of different approaches for different cases such as a periangular with a vestibular, a preauricular and a retromandibular with a vestibular were used according to the type of fractures. The accessibility to one difficult case with a medially displaced condyle was facilitated by using Hegar's uterine dilators. In all cases, good anatomical reduction was achieved with stable occlusion and without any signs of facial nerve impairment. The 'Condyle first' approach in the surgical management of double/triple mandibular fractures, is a reliable and efficient technique.

Imaging in traumatic mandibular fractures

A fracture of the mandible is a common trauma presentation amongst young males and represents one of the most frequently encountered fractured bones within the viscerocranium. Historically, assault was the dominant contributing factor but now due to the increased number of vehicles used per capita, motor vehicle accidents are the primary cause. Mandibular fractures can be classified anatomically, by dentition, by muscle group and by severity. The fracture may also be closed, open, comminuted, displaced or pathological. It is important that the imaging modality used identifies the classification as this will decide definitive treatment. X-ray projections have typically been used to detect a mandibular fracture, but are limited to an anteroposterior (AP), lateral and oblique view in an unstable trauma patient. These views are inadequate to detail the level of fracture displacement and show poor detail of the condylar region. Computer tomography (CT) is the imaging modality of choice when assessing a traumatic mandibular injury and can demonstrate a 100% sensitivity in detecting a fracture. This is through use of a multidetector-row CT, which reduces motion blur and therefore produces accurate coronal and sagittal reconstructions. Furthermore, reconstructive three-dimensional CT images gained from planar views, allows a better understanding of the spatial relationship of the fracture with other anatomical landmarks. This ensures a better appreciation of the severity and classification of a mandibular fracture, which therefore influences operative planning. Ultrasound is another useful modality in detecting a mandibular fracture when the patient is too unstable to be transferred to a CT scanner. The sensitivity however is less in comparison to a CT series of images and provides limited detail on the fracture pattern. Magnetic resonance imaging demonstrates use in assessing soft tissue injury of the temporomandibular joint but this is unlikely to be of priority when initially assessing a trauma patient.

Finite Element Evaluation of Stable Fixation in Combined Mandibular Fractures

PURPOSE

The fixation of combined mandibular fractures, especially symphyseal-condylar fractures, although occurring commonly and having a higher complication rate in the clinic, is rarely investigated regarding predictable therapeutic approaches. Thus this study's aim was to assess different forms of condylar fixation when combined with symphyseal fracture fixation.

MATERIALS AND METHODS

Using finite element models, we analyzed the stress distribution that occurs when a condylar fracture is fixed with 1 miniplate, 2 miniplates, or a trapezoidal condylar miniplate and when a symphyseal fracture is fixed with 2 parallel plates, 2 perpendicular plates, or 2 lag screws. The null hypothesis was that there would be no differences among the different fixation techniques.

RESULTS

The results showed a stress concentration in the anterior region of the condyle, close to the sigmoid notch. Moreover, adequate fixation in the symphysis could result in less tension at the condylar region. Therefore, when the symphysis was fixed with a lag-screw technique, condylar fixation was less required, showing a more adequate stress distribution when the condyle was fixed with 1 or 2 plates. Conversely, when the symphyseal fixation was less effective, by use of perpendicular plates, there was a change in the stress distribution at the condylar region, altering fixation behavior and resulting in more tension and displacement in the condyle, especially when a trapezoidal plate was used.

CONCLUSIONS

A lag screw and parallel double plates appear to be suitable for symphyseal fixation, whereas 2 straightly positioned plates and a trapezoidal plate are suitable for condylar fixation. However, the combination of perpendicular plates in symphyseal fixation and a trapezoidal plate in condylar fixation showed an altered stress distribution.