A comparison of outcomes between immediate and delayed repair of mandibular fractures

Identification of temporal shifts of oral bacteria in bone regeneration following mandibular bone defect injury and therapeutic surgery in a porcine model

BACKGROUND

Considered the second largest and most diverse microbiome after the gut, the human oral ecosystem is complex with diverse and niche-specific microorganisms. Although evidence is growing for the importance of oral microbiome in supporting a healthy immune system and preventing local and systemic infections, the influence of craniomaxillofacial (CMF) trauma and routine reconstructive surgical treatments on community structure and function of oral resident microbes remains unknown. CMF injuries affect a large number of people, needing extensive rehabilitation with lasting morbidity and loss of human productivity. Treatment efficacy can be complicated by the overgrowth of opportunistic commensals or multidrug-resistant pathogens in the oral ecosystem due to weakened host immune function and reduced colonization resistance in a dysbiotic oral microbiome.

AIMS

To understand the dynamics of microbiota's community structure during CMF injury and subsequent treatments, we induced supra-alveolar mandibular defect in Hanford miniature swine (n = 3) and compared therapeutic approaches of immediate mandibullar reconstructive (IMR) versus delayed mandibullar reconstructive (DMR) surgeries.

METHODS

Using bacterial 16S ribosomal RNA gene marker sequencing, the composition and abundance of the bacterial community of the uninjured maxilla (control) and the injured left mandibula (lingual and buccal) treated by DMR were surveyed up to 70-day post-wounding. For the injured right mandibula receiving IMR treatment, the microbial composition and abundance were surveyed up to 14-day post-wounding. Moreover, we measured sera level of biochemical markers (e.g., osteocalcin) associated with bone regeneration and healing. Computed tomography was used to measure and compare mandibular bone characteristics such as trabecular thickness between sites receiving DMR and IMR therapeutic approaches until day 140, the end of study period.

RESULTS

Independent of IMR versus DMR therapy, we observed similar dysbiosis and shifts of the mucosal bacteria residents after CMF injury and/or following treatment. There was an enrichment of Fusobacterium, Porphyromonadaceae, and Bacteroidales accompanied by a decline in Pasteurellaceae, Moraxella, and Neisseria relative abundance in days allotted for healing. We also observed a decline in species richness and abundance driven by reduction in temporal instability and inter-animal heterogeneity on days 0 and 56, with day 0 corresponding to injury in DMR group and day 56 corresponding to delayed treatment for DMR or injury and immediate treatment for the IMR group. Analysis of bone healing features showed comparable bone-healing profiles for IMR vs. DMR therapeutic approach.

Time-to-operation delays and in-hospital complications in operative facial trauma: A national analysis

BACKGROUND

Management of facial fractures is variable. Understanding how time to operative management impacts outcomes can help standardize practice.

METHODS

Retrospective analysis of the ACS Trauma Quality Improvement Program (TQIP) database between 2016 and 2019. Adult patients with operative facial fractures were isolated by ICD-10 procedure codes, and further stratified by fracture location, including the mandible, orbit, maxilla, zygoma, and frontal bone. Multivariable logistic regression was conducted to predict in-hospital complications (both surgical and systemic complications) adjusting for time-to-operation, comorbidities, fracture location, AIS, and demographics.

RESULTS

1678 patients with operative facial fractures were identified. The median time-to-operation was 2 days (IQR 1.0-2.0 days). Most patients only had one operative fracture (95 %) and orbital fracture was the most common (44 %). The overall complication rate was higher for those operated after 2 days compared to those operated between 1 and 2 days and within 24 h (2.8 % vs 0.6 % vs 0.7 %; p < 0.001). Patients who were operated on after 48 h exhibited an increased risk of any complication (OR 4.72, 95 % CI 1.49-16.6, p = 0.010) on multivariable models.

CONCLUSION

Delays in the management of facial fractures are associated with more in-hospital complications. However, the incidence of short-term postoperative complications remains low. Injury characteristics are the primary predictor of delays in operation, however Hispanic patients independently experienced delays in care.

Surgical Correction of Post-traumatic Residual Deformity of the Mandible: A Case Report

Mandibular fractures are the most common trauma cases that we often come across in our day-to-day practice of oral and maxillofacial surgery. Various factors can lead to deformities and make those cases more challenging, which includes a delay in surgical treatment, resulting in non-union or malunion of the fracture site causing occlusal disturbances and functional abnormalities in the temporomandibular joint.

Isolated favorable compound mandibular body fractures: A retrospective review of two cohorts of patients based on the timing of treatment

BACKGROUND/AIM

Treatment delays in the management of mandible fractures are often unavoidable and, as a result, the timing of treatment of mandibular fractures has remained a contentious issue in clinical practice as the optimal treatment delay for minimizing complications remains unknown. The aim of this study was to determine the rate and types of complications between two cohorts of patients designated as early and late treatment groups and estimate an optimal time threshold for treatment delay after closed reduction and maxillomandibular fixation.

MATERIAL AND METHODS

Demographic and clinical data were collected retrospectively about patients who were treated for isolated, unilateral, favorable, and compound mandibular body fractures between 1999 and 2019 to answer the question of whether treatment delay is an independent variable impacting post-operative mandible body fracture complications. Descriptive and bivariate statistics were computed.

RESULTS

One hundred and seventy subjects were evaluated (n = 87 in the control/early group and n = 83 in the study/late group). The mean time lapses from injury to treatment were: early (5.8 ± 0.4 days) and late (10.3 ± 0.7 days). The overall complication rate was 14.1%. However, the complication rates of the early and late groups were 13.8% and 14.5%, respectively, with no significant difference (p = 0.89).

CONCLUSIONS

There was no difference between early and late treatment groups. Treatment delay was not an independent variable impacting post-operative mandible body fracture complications if treatment is done between 3 and 12 days after the injury.

Outpatient management of facial fractures in France: Current state

Maxillofacial trauma is still very common in France with possible involvement of all face bones. Outpatient surgery is an axis strongly put forward by the public authorities. The aim of this study is to establish a current state in the outpatient management of facial fractures in France in 2019 before COVID infection. A closed and semi-open-ended questionnaire was sent to French hospitals treating facial fractures in order to evaluate current and possible future practices in terms of outpatient and perioperative management. Data extracted from the Program for giving Medical significance to Information Systems (PMSI) thanks to the Agency for Information on Hospital Care (ATIH) were also studied to obtain proportions of outpatient care by department. About the questionnaire 43 replies were received. Nasal fractures were the only type of fracture having a minimum average length of stay below 24hours (12.00±16.65) as well as an actual average length of stay (14.22±24.24). Concerning data extracted from the PMSI, 14510 stays were found. Currently only nasal fractures and zygomatic arch fractures requiring simple reduction without osteosynthesis are performed on an outpatient basis. Mandibular fractures could be performed as an outpatient procedure. Access to the operating room and organizational problems specific to each center are factors that limit the development of outpatient management of these facial fractures. Some incompressible parameters such as the monitoring required following the management of these fractures as well as the patients' comorbidities must be taken into account.

Is Outpatient Management of Mandibular Fractures Associated With Inflammatory Complications? An ACS-NSQIP Study

PURPOSE

Timing of mandibular fracture repair has long been debated. The purpose of the present study was to assess the incidence of postoperative inflammatory complications (POICs) following open repair of mandibular fractures managed non-urgently in the outpatient setting versus urgently in the inpatient setting.

METHODS

The authors utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to enroll a sample of patients with mandibular fractures who underwent open repair. The primary independent variable was treatment protocol: outpatient (elective) versus inpatient (urgent/non-elective). The primary dependent variable was POIC (yes/no). Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between treatment protocol and POICs.

RESULTS

The study cohort was comprised of 1,848 subjects with 1,134 outpatients and 714 inpatients. The incidence of POICs was 6.53% for the outpatient group compared to 8.96% for the inpatient group, with no significant difference between groups (P= .052). However, subjects treated as inpatients were 1.51 times more likely to experience any complication (P = .008) due to an increase in non-POICs (P = .028), in particular urinary tract infections (P = .035). After adjusting for age, hypertension requiring medical treatment, and smoking, classification as ASA II (P = .046, OR = 2.21, 95% CI 1.01 to 4.83), ASA III (P = .020, OR = 2.88, 95% CI 1.18 to 7.02), diabetes (P = 0.004, OR = 3.11, 95% CI 1.43 to 6.74), and preoperative hematocrit (P = 0.010, OR = 0.950, 95% CI 0.913 to 0.988) were independent predictors of POICs. Length of stay was 0.83 ± 2.61 days compared to 2.36 ± 3.63 days for the outpatient and inpatient groups, respectively (P ≤ .001).

CONCLUSIONS

There was no significant difference in POICs between patients treated as outpatients versus inpatients, though outpatients had fewer non-POICs and a shorter length of hospital stay.

Risk Factors Associated With Complications After Treatment of Mandible Fractures

Importance

Complications that arise after treatment of mandible fractures can result in significant morbidity. Identifying modifiable risk factors associated with these complications is valuable in guiding clinical practice for improved patient outcomes.

Objective

To describe the risk factors associated with complications in patients undergoing treatment for mandible fracture.

Design, Setting, and Participants

A retrospective review was conducted of 137 patients presenting to a tertiary care, level 1 trauma center with mandible fractures between January 1, 2014, and January 1, 2017. Outcomes and demographic characteristics for patients with at least 3 weeks of follow-up were compared using multivariate logistic regression analysis.

Results

Of the 137 patients meeting inclusion criteria, there were 113 males (82.5%) and 24 females (17.5%), with a mean (SD) age at presentation of 32.3 (15.7) years. Median follow-up was 71 days (range, 22-1189 days). Postoperative complications were identified in 29 patients (21.2%); complications included wound dehiscence or surgical site infection (n = 17), bony nonunion (n = 5), and hardware exposure (n = 13). Complications were managed surgically in 19 patients and nonsurgically in 10 patients. On univariate analysis, the initial surgery was completed later (mean [SD], 5.9 [6.6] days after injury) in patients who developed complications than in those who did not (mean [SD], 3.8 [4.0] days). On multivariate analysis, complications were associated with increased time from injury to treatment (odds ratio [OR], 1.60; 95% CI, 1.02-2.53; P = .04), tobacco use (OR, 8.10; 95% CI, 1.26-52.00; P = .03), and dental extraction (OR, 93.00; 95% CI, 1.19 to >999.00; P = .04). Residence in the same city as the medical center was associated with fewer complications (OR, 0.08; 95% CI, 0.01-0.69; P = .02).

Conclusions and Relevance

In a 3-year review of mandible fractures managed at a single academic center, complications were associated with an increased time to treatment, tobacco use, dental extraction, and living farther from the treatment facility. On a systems level, the results of this study suggest that expediting intervention for mandible fractures may improve outcomes.

Level of Evidence

3.

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.

Treatment Delay Impact on Open Reduction Internal Fixation of Mandibular Fractures: A Systematic Review

BACKGROUND

The impact of mandible fracture treatment delay has been contested in the literature for decades, with conventional wisdom favoring earlier surgical treatment to prevent postoperative complications, primarily infection. Through a systematic review of all available evidence, this study aims to determine whether delay to open reduction and internal fixation of traumatic mandibular fractures influences outcomes.

METHODS

MEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched for English language literature pertaining to the above research question and screened in duplicate. Methodological quality scoring was performed using MINORS criteria. Qualitative and quantitative findings from relevant studies are presented.

RESULTS

Twenty eligible studies including 2,671 patients had open reduction internal fixation, with or without adjunct mandibulomaxillary fixation. All studies were observational cohort or case-control studies of low methodological quality with a mean MINORS score of 6.5 of 16 (40.6%) for noncomparative studies and 11.2 of 24 (46.7%) for comparative studies. Only 5 of 20 (25%) studies recommended earlier treatment. Due to insufficient reporting of data and study heterogeneity, the impact of treatment delay on complications could not be quantitatively analyzed.

CONCLUSIONS

There is substantial heterogeneity and no consensus on the definition of "early" versus "delayed" surgical treatment for patients with traumatic mandibular fractures. The majority of included studies do not make a recommendation for earlier treatment. Future, well-designed prospective studies are essential to determine if there is an optimal surgical treatment delay of mandibular fractures that mitigates the risk of infectious and noninfectious complications.

Flail Mandible and Immediate Airway Management: Traumatic Detachment of Mandibular Lingual Cortex Results in Obstructive Dyspnea and Severe Odynophagia

Isolated mandibular fractures usually represent themselves as non-life-threatening injuries and are not treated in emergency setting. However, some rare patterns of them may result in airway obstruction as a result of displacement of bony fragments. The authors report a patient of an open comminuted fracture of mandibular symphysis which exhibited an uncommon split pattern with retrogression of lingual cortical plate, and thereby induced glossoptosis, painful deglutition, and obstruction of the upper airway within a few hours. The patient underwent immediate intubation for establishing a definitive airway, followed by open reduction and internal fixation of fracture. Surgical airway management was not needed. Anatomic reduction of the fracture was achieved, by reestablishing the patency of upper airway and resolving the painful deglutition. Patient's occlusion and mouth opening returned to the preinjury status. Timely osteosynthesis surgery offered early relief of patient's signs and symptoms, prevented airway complications and development of traumatic mandibular osteomyelitis, as well as obviated the potential need for surgical airway management. The appropriate management of mandibular fractures placing the airway at risk requires immediate diagnosis based on knowledge of specific clinical and radiographic findings. This case emphasizes that emergency clinicians should be able to distinguish those patients who will need airway securing techniques in emergent or prophylactic context, due to an uncommon fracture pattern of facial skeleton. Moreover, emergency clinicians should be conversant with wiring techniques to achieve stabilization of the mandibular framework and to control the pain, hemorrhage, and airway patency.

A comparative study between traditional fixation with miniplates and modified lag screws for the treatment of mandibular fractures

OBJECTIVES

The objective of this study is to investigate two internal fixation surgical techniques for mandibular fractures in order to compare modified lag screw techniques with standard miniplates.

MATERIALS AND METHODS

This is an observational prospective study. Three hundred eighteen patients were operated on for mandibular fractures. The patients were divided into two groups according to the type of surgical technique used: modified lag screws (155 patients) and traditional miniplates (163 patients). Analyses were made of sociodemographic and preoperative variables, the parameters related to the fracture type and postoperative data.

RESULTS

There were no differences between the two groups regarding their sociodemographic characteristics. The modified lag screws were primarily used with double fractures, while conventional miniplates were more often used with simple fractures. The number of complications was higher with the miniplate technique. The unfavorable fractures had an OR of 5.75 due to postoperative complications; double fractures had an OR of 8.87 and simple fractures an OR of 19.53, which, in both cases, were lower with conventional miniplates than with modified lag screws.

CONCLUSION

Modified lag screws provide a rigid fixation system that is as secure as miniplates, but with greater compression between the fragments, less postsurgical gap, faster ossification, and fewer postoperative complications.

CLINICAL RELEVANCE

The modified screw technique is a safe tool that does not require any specific osteosynthesis materials not found in a basic traumatology kit and has a lower cost, due to the reduced amount of material used.

Comparison of Efficacy of Amoxicillin versus Ciprofloxacin in Postsurgical Management of Transalveolar Extraction

Background:

The transalveolar extraction and the use of pharmacological antibiotic therapy following the surgical procedure in management of postoperative infection go hand in hand in minor oral surgery. Attention has often been focused on antibiotic therapy administered at different time schedules (before or after surgery or both). This investigation reveals how the use of different molecules and dosages is critical in the postoperative period and has always provided positive result.

Methodology:

A prospective randomized study was carried out in 100 healthy controls of age group 20–50 years undergoing transalveolar extraction in the Department of Oral and Maxillofacial Surgery, Vivekanandha Dental College for Women. A 5-day regimen of amoxicillin or ciprofloxacin group of antibiotics along with regular analgesics was administered to the patients following transalveolar extraction. The patients were evaluated for postoperative infection, inflammation and wound care on postoperative days: day zero, day 2, day 5, day 7, day 15, day 30, and analyzed. A P < 0.05 was considered statistically significant.

Results and Conclusion:

A total of 100 patients aged 23–50 years (24.6–4.43) met the inclusion criteria. Male accounted for 44, while female were 55, giving male:female ratio 1:1.4. Postoperative infection was minimum with ciprofloxacin group as compared to amoxicillin group and was more significant (P < 0.005) on evaluation. A complete review has also been taken into an account, various strategies used such as surgical flaps, no traumatic osteotomy, and primary or secondary closure.

Management of Mandibular Angle Fractures by Two Conventional 2.0-mm Miniplates: A Retrospective Study of 389 Patients

Fractures of the mandibular angle account for 23 to 42% of all facial fractures with a high complication rate (0-32%). Although the ideal treatment remains debatable, two main procedures are commonly used to manage the majority of mandibular angle fractures that are open reduction and internal fixation by a noncompression miniplate placed on the external oblique ridge with or without a second miniplate on the outer cortex. The purpose of this study was to describe our management of mandibular angle fractures by two noncompression miniplates placed on the outer cortex via a transbuccal approach. Medical records and radiographic examination of 389 patients (258 males [66.3%] and 131 females [33.7%]) operated from January 2000 to December 2012 were retrospectively reviewed. Postoperative complications including malocclusion, infection, wound dehiscence, nonunion, and reoperative surgery were recorded and analyzed. Fifty-three patients developed postoperative complications (overall complication rate: 13.6%). No significant difference was found in the complication rate by age and gender variables and regarding the interval between the trauma and the operation and the presence of the teeth in the line of fracture. A higher rate of complications was found among patients with alcohol/drug addiction and in patients with multiple-site involvement. The findings of this study suggest that the use of two transbuccal miniplates placed on the outer cortex for the internal fixation of mandibular angle fracture provided a low rate of complications. The global incidence of screw loosening, wound dehiscence, plate exposure, infection, reoperation, and plate removal were similar with the data reported in the literature with improved health outcomes, lower postoperative morbidity, and a faster return to normal life.

Mandibular fractures - towards a national standard for "time to theatre" - national audit by the BAOMS Trauma Specialist Interest Group

Recent studies have shown that in most patients, a delay of several days in the treatment of mandibular fractures is not associated with adverse outcomes, and this has challenged the traditional practice of recommending treatment within 24hours. Longer hospital stays cost more and lower the patients' quality of life, but we know of no standard recommendation about when these patients should be treated. Our aim therefore was to find out how many patients had reduction and fixation of a fractured mandible by the end of the next working day, with a view to developing a national standard. We invited all oral and maxillofacial surgery (OMFS) units in the UK to participate in a prospective audit over two months, and 35 agreed. Overall, 506 patients (80%) were operated on by the end of the next working day. The time to theatre varied from 1 hour 15minutes to 11 days, 20hours and 51minutes (median 22hours 7minutes). Patients admitted to units with an OMFS trauma list were more likely to be operated on by the next working day (p=0.011) as were those operated on at the weekend (p=0.019). We think that early fixation, return of function, and discharge, benefit patients most in terms of quality of life. Also, shorter hospital stays and reduced costs increase the availability of resources for elective operations. Setting a standard will improve our service and the care we deliver.

Inflammatory Morbidity due to Compound Mandibular Body Fractures: Does It Have a Relationship with Treatment Outcome?

OBJECTIVE

The aim of this study was to evaluate the relationship between the degree of preoperative pain and trismus with the development of complications following the repair of isolated unilateral compound mandibular body fractures using a closed reduction technique.

SUBJECTS AND METHODS

This was a 7-year prospective study carried out at the Dental and Maxillofacial Surgery Clinic of the University of Calabar Teaching Hospital, Calabar, Nigeria. Of a total of 97 patients, 83 (85.6%) subjects (66 males, 17 females, ratio 5:1) were preoperatively evaluated for trismus and pain in a blinded manner by a single examiner, and complications were recorded postoperatively. The data obtained were statistically analyzed with EPI Info 2008 software.

RESULTS

Of the 83 patients treated, 13 (15.7%) developed complications. The fractures were most common in the age range of 21-40 years (n = 45, 54.2%). The age (p = 0.02) and gender (p = 0.01) distribution of the subjects was significant. The more severe the limitation of mouth opening (p = 0.03) and pain (p = 0.04) before treatment, the more complications developed, and these significantly affected treatment outcome. Impaired mastication and facial asymmetry (n = 17, 41.5%) were the most common complications.

CONCLUSION

This study showed that posttrauma pain and trismus due to unilateral mandibular body fractures may be associated with the development of complications. An adequately powered prospective study treating patients at 5 or 7 days is required in order to make the case for later intervention.

Outcomes of mandible fracture treatment at an academic tertiary hospital: a 5-year analysis

PURPOSE

To analyze the outcomes of mandible fractures treated using open reduction and internal fixation.

PATIENTS AND METHODS

We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded.

RESULTS

Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495).

CONCLUSIONS

A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.