Avoiding occlusal derangement in facial fractures: An evidence based approach

Digital technology revolutionizing mandibular fracture treatment: a comparative analysis of patient-specific plates and conventional titanium plates

OBJECTIVES

The treatment of fractures prioritizes the restoration of functionality through the realignment of fractured segments. Conventional methods, such as titanium plates, have been employed for this purpose; however, certain limitations have been observed, leading to the development of patient-specific plates. Furthermore, recent advancements in digital technology in dentistry enable the creation of virtual models and simulations of surgical procedures. The aim was to assess the clinical effectiveness of patient-specific plates utilizing digital technology in treating mandibular fractures compared to conventional titanium plates.

MATERIALS AND METHODS

Twenty patients diagnosed with mandibular fractures were included and randomly assigned to either the study or control groups. The surgical procedure comprised reduction and internal fixation utilizing patient-specific plates generated through virtual surgery planning with digital models for the study group, while the control group underwent the same procedure with conventional titanium plates. Assessment criteria included the presence of malunion, infection, sensory disturbance, subjective occlusal disturbance and occlusal force in functional maximum intercuspation (MICP). Statistical analysis involved using the Chi-square test and one-way repeated measures analysis of variance.

RESULTS

All parameters showed no statistically significant differences between the study and control groups, except for the enhancement in occlusal force in functional MICP, where a statistically significant difference was observed (p = 0.000).

CONCLUSION

Using patient-specific plates using digital technology has demonstrated clinical effectiveness in treating mandibular fractures, offering advantages of time efficiency and benefits for less experienced surgeons.

CLINICAL RELEVANCE

Patient-specific plates combined with digital technology can be clinically effective in mandibular fracture treatment.

Assessment of the Wisconsin Criteria at a Level I Trauma Center

ABSTRACT

The Wisconsin Criteria was developed for physicians evaluating facial trauma to determine the likelihood of facial fractures. Subsequent studies have not consistently validated these criteria. This study seeks to validate the Wisconsin Criteria and determine its utility in predicting operative facial fractures.Retrospective chart review of the trauma database registry at a Level I Trauma Center was conducted from September 2011 to May 2019. Adult patients who had a complete facial examination by otolaryngology or plastic surgery as well as a head computed tomography scan completed, were included. Fisher exact test was utilized for statistical analysis (P < 0.05) and positive predictive value, and negative predictive value (NPV) were calculated with a 95% confidence interval.After screening, 546 patients met eligibility, 448 had at least 1 finding of the Wisconsin Criteria, and 472 patients had facial fractures. The sensitivity of the Wisconsin Criteria for determining the presence of a facial fracture was 86.23%, the specificity was 44.59%, and the NPV was 33.67% (P < .0001). Malocclusion was the criterion most specific in determining if a facial fracture was present (98.65%), and Glasgow Coma Score < 14 was the least specific (67.57%).The Wisconsin Criteria did aid in the identification of facial fractures in trauma patients with a comparable sensitivity, higher specificity, and much lower NPV than originally described. Further investigation should be done to validate the criteria in other large trauma centers.

A Novel Approach to the Treatment of Le Fort Fractures Using Internal Fixation to Achieve Mandibulomaxillary Fixation

Background:

We aimed to determine the minimum effective period of mandibulomaxillary fixation after the inadequate internal fixation of Le Fort I or Le Fort II fracture.

Objective:

The aim of this study was to investigate the stability of the skeleton after the treatment of Le Fort I or Le Fort II fractures by measuring bite forces and to determine the minimum time required for effective mandibulomaxillary fixation following treatment with internal fixation and mandibulomaxillary fixation.

Method:

A prospective study was performed to examine the treatment of Le Fort I or Le Fort II fracture in the Department of Maxillofacial Surgery at the National Hospital of Odonto-Stomatology in Ho Chi Minh City, Vietnam. A total of 31 patients were included, with up to 1 month of follow-up after discharge from the hospital. Midface bone stability and the mandibulomaxillary fixation time were evaluated using bite force criteria after 1, 2, and 4 weeks.

Results:

Midface bone stability values 1, 2, and 4 weeks after treatment were 87.1%, 100%, and 100%, respectively. After 1 week, 87.1% of patients achieved intermaxillary fixation, and 96.3% of these patients were treated with at least three rigid plates. The remaining 12.9% of patients achieved fixation after 2 weeks, and all of these patients were fixed only at zygomaticomaxillary sutures (p < 0.05). Bite forces increased significantly at 2 weeks compared with 1 week and at 4 weeks compared with 2 weeks (p < 0.05).

Conclusion:

When treated using only rigid fixation, through the placement of plates and screws at zygomaticomaxillary buttresses, patients with Le Fort I and Le Fort II fractures can achieve mandibulomaxillary fixation after 2 weeks. For Le Fort I fractures, rigid fixation using plates and screws at zygomaticomaxillary buttresses and canine buttress at three positions can achieve mandibulomaxillary fixation after only 1 week (p = 0.0001).

Evaluation of Bite Force After Treatment of Le Fort Fractures by Internal Fixation and Mandibulomaxillary Fixation

Objectives:

Evaluation of bite force one, two, and four weeks after discharge following treatment of Le Fort I and/or Le Fort II fracture by rigid fixation and mandibulomaxillary fixation.

Objective:

The aim of this study was to evaluate bite force following treatment of Le Fort I and/or Le Fort II fractures by rigid fixation and mandibulomaxillary fixation at one, two, and four weeks after discharge. This provides valuable results to guide the development of a treatment protocol for Le Fort fractures.

Method:

This was a prospective study including 31 patients who underwent followup examination three times after being discharged from hospital. The examination evaluated bite force using a bite force meter in the right molar, left molar, and incisor regions.

Results:

One week after discharge, bite forces in the right molar, left molar, and incisor regions were 94.29 ± 58.80 N, 95.42 ± 57.34 N, and 39,94 ± 30,29 N, respectively. Two weeks after discharge, bite forces in the right molar, left molar, and incisor regions were 153.84 ± 89.14 N, 153.00 ± 78.55 N, and 65,9 ± 43.89 N, respectively. Four weeks after discharge, bite forces in the right molar, left molar, and incisor regions were 279.77 ± 95.46 N, 285.00 ± 90,47 N, and 123.42 ± 54.04 N, respectively.

Conclusions:

Bite forces in the right molar, left molar, and incisor regions were significantly increased one week, two weeks, and four weeks after discharge. Bite force may be a helpful parameter to confirm the stability of the midface bone after treatment of Le Fort fractures.

Postoperative Computed Tomography for Facial Fractures

In order for a radiologist to create reports that are meaningful to facial reconstructive surgeons, an understanding of the principles that guide surgical management and the hardware employed is imperative. This article is intended to promote efficient and salient reporting by illustrating surgical approaches and rationale. Hardware selection can be inferred and a defined set of potential complications anticipated when assessing the adequacy of surgical reconstruction on postoperative computed tomography for midface, internal orbital, and mandible fractures.

The evaluation of alveolar fractures of trauma patients in Iran

BACKGROUND

Alveolar bone plays a vital role in mastication and supporting the teeth. The alveolar process is one of the most challenging regions of facial bone to reconstruct due to the deformity involves both hard and soft tissues. However, the etiology, gender, and age distribution vary between different regions, cultures, and countries. This study aims to investigate the prevalence of alveolar trauma in Shahid Rajaee Hospital, Shiraz, Iran, for three years.

METHODS

In a retrospective cross-sectional study, patients with alveolar fractures referred to Shahid Rajaei Hospital in Shiraz were included in the study. Age, sex, site of alveolar fractures, and etiology factors of trauma explored. The collected data was analyzed by SPSS software. Mean [Formula: see text] SD calculated for the inferential statistics, and the data compared using Chi-square and Exact Fisher. A p-value of < 0.05 was considered statistically significant with a 95% reliability.

RESULTS

A total of 165 patients had alveolar fractures in this study. We found that the most common cause of alveolar fracture was road accidents (32.3%) and the lowest reason was violence (9%). Most people with alveolar trauma were male and in the 21-30 years. The prevalence of mandibular and maxillary alveolar fractures was 17.61 and 17.01%, respectively, with the most anterior area of injury.

CONCLUSION

Alveolar trauma is one of the most common injuries among trauma patients. Early diagnosis and treatment plans are necessary to reduce the complications of facial trauma. Early training for a young adult is essential to prevent the severity of trauma.

Le Fort Fractures With Maxillary Immobility: Classification and the Moment Concept to Rationalize Optimal Surgical Treatment

BACKGROUND

Le Fort fractures with maxillary immobility are an uncommon presentation of facial trauma often associated with the disturbance of occlusion. Historically, cases involving high Le Fort fractures require a coronal extensive approach to mobilize the maxilla for occlusion restoration. Here, we review our institutional series of immobile Le Fort fractures and present their treatment approach, outcomes, classification, and then rationalize our treatment with a concept philosophy.

MATERIALS AND METHODS

We treated 12 consecutive patients with unilateral and bilateral immobile Le Fort fractures from 2010 to 2017. The mean age was 27.1 years. Ten patients had a unilateral greenstick Le Fort III fracture. Five patients also had associated mandible fractures. Intraoperative occlusions could only be restored after Le Fort I osteotomy was performed on the side of the immobile Le Fort fracture. The mean follow-up period was 1.6 years.

RESULTS

All patients presented good long-term occlusion restoration. There were no cases of nonunion or significant complications. None of the patients complained of any malar or periorbital cosmetic issues during follow-up sessions.

CONCLUSIONS

We presented an institutional series and classification of unusual Le Fort fractures with maxillary immobility, including a previously unreported fracture configuration of greenstick unilateral Le Fort III fractures combined with complete contralateral Le Fort I fracture. Based on our moment concept to rationalize treatment, as well as a systematic review of published literature, we advocate the judicious use of Le Fort I osteotomy to efficiently and safely treat these unusual fractures.

CTRead-A Revolutionary Approach to Training Residents in Computed Tomography Facial Bone Interpretation

PURPOSE

The purpose of our study was to create an online, web-based training module that would instruct a group of residents in the interpretation of a computed tomography (CT) facial bone scan in a logical, stepwise manner to locate and identify all relevant facial fractures. Our hypothesis was that implementing the CTRead facial bones training module would improve residents' competency in the interpretation of CT facial bone scans.

MATERIALS AND METHODS

We designed and implemented a prospective quasi-experimental trial. The population for the present study included medical and dental residents. The primary outcome variable was the difference between the pre- and post-test scores of the participants and the frequency of missing fractures before and after the course. The secondary outcomes of interest were subjective data gathered from the course, including participants' feedback and subjective evaluation of the training module and perceived benefit. Another secondary outcome measured was the residents' self-reported confidence level in interpreting the CT facial bone scans on their own before and after completion of the course. Descriptive and bivariate statistics were used.

RESULTS

The population sample included 38 residents from North America, aged 25 to 34 years (mean, 28.2 years). When comparing the results from before and after the course, the overall frequency of missed fractures had decreased from 20.7 to 6.4 (P < .001), and the total score overall had increased from 32.7 to 74.7% (P < .001). Regarding the secondary outcomes, most participants indicated that they agreed or strongly agreed with a number of positive subjective queries. In addition, we found a statistically significant increase in the participants' comfort level in the interpretation of CT facial bone scans.

CONCLUSIONS

The results of the present study have confirmed the hypothesis that completing the CTRead training module (available at: www.CTRead.ca) improves competency among residents in the interpretation of CT facial bone scans and their correctly identification of facial fractures.

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

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

Malocclusion after open reduction of midfacial fracture: a case report

Malocclusion is a serious complication of open reduction surgery for facial fractures. It is often caused by the lack of adequate consideration for the occlusal relationship before the trauma and intermaxillary fixation during the operation. This is a case report of postoperative malocclusion that occurred in a patient with a midfacial complex fracture.

A Comparative Study of Transbuccal and Extraoral Approaches in the Management of Mandibular Angle Fractures: A Systematic Review

AIM

The aim of the present study was to compare the extraoral and transbuccal approaches for the treatment of mandibular angle fractures with regard to postoperative complications.

PATIENTS AND METHODS

An electronic search for relevant articles without language and date restrictions was performed in July 2016. Inclusion criteria were studies in humans including randomised controlled trials (RCTs), controlled clinical trials (CCTs), prospective studies (PS), and retrospective studies (RS). In total, 107 patients were included from four studies (transbuccal = 48, extraoral = 59). The follow-up period varied from 3 months to 24 months.

RESULTS

In extraoral group the average of unsightly scar, facial nerve weakness, infection, malocclusion, plate removal were found to be 55% (range, 10% -100%), 26.5% (range, 0%-53%), 11.7% (range, 0% - 20%), 22.5% (range, 0% -50%), 6.7% (range, 3.3% - 10%) respectively while these parameters in the transbuccal approach were found to be no obvious unsightly scar, 6.6 % (range, 0%-13.3%), 8.1% (range, 0% - 20%), 4.8% (range, 0% - 12.5%), 0%. The incidence of postoperative trismus and nonunion/malunion were 0% in both groups.

CONCLUSION

The results of this study suggest that transbuccal approach shows fewer complications than extraoral approach when used for the treatment of mandibular angle fractures.

Interrelationship of Structure and Function in Maxillofacial Fractures

Surgical fixation of maxillofacial fractures can be associated with a myriad of surgical complications. Specific complications correlate with the type of fracture. The authors present a case of multiple maxillofacial fractures, briefly review various types of fractures, and discuss the operative decision-making process. This case report serves as an important reminder that the operative decision-making process should take into account a patient's entire clinical condition.