Unfavourable outcomes in maxillofacial injuries: How to avoid and manage

In Vivo Evaluation of Collagen and Chitosan Scaffold, Associated or Not with Stem Cells, in Bone Repair

Natural polymers are increasingly being used in tissue engineering due to their ability to mimic the extracellular matrix and to act as a scaffold for cell growth, as well as their possible combination with other osteogenic factors, such as mesenchymal stem cells (MSCs) derived from dental pulp, in an attempt to enhance bone regeneration during the healing of a bone defect. Therefore, the aim of this study was to analyze the repair of mandibular defects filled with a new collagen/chitosan scaffold, seeded or not with MSCs derived from dental pulp. Twenty-eight rats were submitted to surgery for creation of a defect in the right mandibular ramus and divided into the following groups: G1 (control group; mandibular defect with clot); G2 (defect filled with dental pulp mesenchymal stem cells-DPSCs); G3 (defect filled with collagen/chitosan scaffold); and G4 (collagen/chitosan scaffold seeded with DPSCs). The analysis of the scaffold microstructure showed a homogenous material with an adequate percentage of porosity. Macroscopic and radiological examination of the defect area after 6 weeks post-surgery revealed the absence of complete repair, as well as absence of signs of infection, which could indicate rejection of the implants. Histomorphometric analysis of the mandibular defect area showed that bone formation occurred in a centripetal fashion, starting from the borders and progressing towards the center of the defect in all groups. Lower bone formation was observed in G1 when compared to the other groups and G2 exhibited greater osteoregenerative capacity, followed by G4 and G3. In conclusion, the scaffold used showed osteoconductivity, no foreign body reaction, malleability and ease of manipulation, but did not obtain promising results for association with DPSCs.

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations

BACKGROUND

Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients.

METHODS

This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures.

RESULTS

Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients.

CONCLUSIONS

High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Tennis-related adult maxillofacial trauma injuries

Objectives: Tennis participation continues to increase amongst adults across the United States. The purpose of this study was to analyze trends in adult tennis-related facial injury epidemiology, demographics, diagnoses, and locations of injury. Materials and methods: The National Electronic Injury Surveillance System was evaluated for tennis-related facial injuries in adults from 2009 through 2018. Number of injuries were extrapolated, and data were analyzed for age, sex, specific injury diagnoses, locations, and discharge disposition. Descriptive statistics were used to present and describe variables of interest. Chi-squared testing (χ2) was performed to compare categorical variables. Results: During the study period, 342 tennis-related facial trauma ED visits were analyzed. Lacerations were the most common injury (45%), followed by contusions or abrasions (33.3%), concussions (11.7%), and fractures (8.5%). The most common sites of injury were the face (47.4%) and head (27.2%) regions. Males accounted for 62.0% of injuries, while females accounted for the remaining 38.0%. Patients between 34-65 years-old accounted for 47.7% of all injuries, and athletes over 65 years-old had the highest rate of fractures (10.1%). Conclusions: Facial trauma incurred secondary to tennis may follow patient-specific patterns. The incidence of tennis-related facial trauma is smaller compared to other sports, but the severity of such injuries remain a danger. Facial protection and enforcement in tennis is virtually absent, and these findings strengthen the need to educate athletes, families, and physicians on injury awareness and prevention.

Analysis of the bone fracture targeting properties of osteotropic ligands

PURPOSE

Although more than 18,000,000 fractures occur each year in the US, methods to promote fracture healing still rely primarily on fracture stabilization, with use of bone anabolic agents to accelerate fracture repair limited to rare occasions when the agent can be applied to the fracture surface. Because management of broken bones could be improved if bone anabolic agents could be continuously applied to a fracture over the entire course of the healing process, we undertook to identify strategies that would allow selective concentration of bone anabolic agents on a fracture surface following systemic administration. Moreover, because hydroxyapatite is uniquely exposed on a broken bone, we searched for molecules that would bind with high affinity and specificity for hydroxyapatite. We envisioned that by conjugating such osteotropic ligands to a bone anabolic agent, we could acquire the ability to continuously stimulate fracture healing.

RESULTS

Although bisphosphonates and tetracyclines were capable of localizing small amounts of peptidic payloads to fracture surfaces 2-fold over healthy bone, their specificities and capacities for drug delivery were significantly inferior to subsequent other ligands, and were therefore considered no further. In contrast, short oligopeptides of acidic amino acids were found to localize a peptide payload to a bone fracture 91.9 times more than the control untargeted peptide payload. Furthermore acidic oligopeptides were observed to be capable of targeting all classes of peptides, including hydrophobic, neutral, cationic, anionic, short oligopeptides, and long polypeptides. We further found that highly specific bone fracture targeting of multiple peptidic cargoes can be achieved by subcutaneous injection of the construct.

CONCLUSIONS

Using similar constructs, we anticipate that healing of bone fractures in humans that have relied on immobilization alone can be greately enhanced by continuous stimulation of bone growth using systemic administration of fracture-targeted bone anabolic agents.

Medico-legal evaluation and trend of the different patterns of maxillofacial fractures concomitant with closed head injury in Upper Egypt: retrospective study

Background

Maxillofacial fractures are of great medico-legal implications because they are of common occurrence with other injuries, predominantly head injuries that might involve serious esthetic and functional problems, and so clinically described as consequential injuries. The aims were to assess the medico-legal aspects of maxillofacial fractured cases concomitant with closed head injury over a 6-year period (2011–2016) in the Trauma Unit of Assiut University Hospitals, Egypt, and to evaluate the demographic feature and the trend of different patterns of such fractures.

Patient and methods

A descriptive hospital-based study included all cases of maxillofacial fractures combined with closed head injury attending the Trauma Unit of Assiut University Hospitals in the period of January 2011 to December 2016.

Results

The study included 1221 cases, the percent of maxillofacial fractures with a closed head injury was 4%, the age group 18–40 years was having the highest incidence, and mean age was 25.9 ± 15.3 years with male to female ratio of 7:1. Road traffic accidents were the main etiology of injury (69.7%), followed by falls (15.1%) and violent assaults (10.2%) while firearm injuries were the last (5%). Unintentional injuries were the commonest in 83.1% followed by homicidal (16.3%); only 7 cases were due to suicidal attacks. The mandibular fracture was the commonest (49.7%) followed by fracture maxilla (19.2%), fracture zygoma (16.8%), and lastly frontal bone and nasal fracture. The trend of maxillofacial fractures over the 6-year period tended to be increased with the highest number in 2011 (21.5%) and the lowest in 2014 (13.3%).

Conclusion

Maxillofacial fracture with a closed head injury in Upper Egypt is common in the middle age with male predominance. Road traffic accident is the main etiologic factor, and accidental trauma is the commonest manner. Mandibular fractures are the commonest pattern followed by fracture maxilla. Traumatic head injuries in cases of maxillofacial fractures were mild in about half of the cases. The trend of maxillofacial fractures over the 6-year period of the study (2011–2016) tended to be increased with the highest number in 2011 and the lowest in 2014.

Efficacy of Microplates versus Miniplates in the Management of Maxillofacial Fractures

Introduction:

Increased facial trauma has led to advances in techniques of internal fixation, improvements in plating system, refinements in exposure of facial skeleton fueling the rapid use of internal fixation for the management of facial fractures. Evaluating 40 patients with confirmed midfacial (Le Fort I and II) and mandibular fractures, this study presents the efficacy of microplate in comparison with miniplate in terms of load bearing capacity, stability at the fracture site and postoperative palpability.

Objectives:

To evaluate the efficacy of microplates in comparison with miniplates in maxillofacial trauma.

Materials and Methods:

Study sample consists 40 subjects, 20 each in two groups clinically and radiographically diagnosed with Group 1 (maxillary) and Group 2 (mandibular fractures) which were subdivided into 10 each treated with miniplate and microplate respectively. Postoperatively, stability of fracture, bite force, need for postop MMF, pain, infection, wound dehiscence, mouth opening, occlusion and palpability was noted. All cases have been evaluated clinically for various parameters for minimum of 3 months to assess any postoperative complications.

Results:

We found microplates are stable enough and have adequate load bearing capacity. Due to close adaptability and less hardware, postoperative palpability is less but larger sample study with long term follow up is necessary to conclude its efficacy in load bearing fracture sites.

On the Court: A Comprehensive Analysis of Basketball Facial Trauma

With basketball gradually becoming increasingly popular across the United States, it is necessary for health care providers to understand injuries associated with the sport. We aim to determine the incidence of basketball-related facial injuries and further describe their patterns with regard to age, mechanism of injury, and degree of injury. An analysis of emergency department visits under the National Electronic Injury Surveillance System was conducted from 2015 through 2017. Chi-squared testing (χ ² ) was performed to compare categorical variables. After a review of results, a total of 4,578 patients were included for analysis spanning a 3-year time period (2015-2017). Lacerations were the most common injury overall (57.9%). Nasal fractures were by far the most common fracture (76.1%), and elbows to the face and collisions with other players were the most common types of injury mechanisms (31 and 28.7%, respectively). Adolescents (aged 12-18 years) were the most frequently injured group (42.5%), although young adults (aged 19-34 years) were also frequently affected (30.1%). Basketball facial trauma remains a prominent issue. Our research, in correlation with previous research, shows that current precautions to injury are not widely observed or are ineffective to the extent of need for further reform. It thus becomes necessary to provide patient education and develop more practical methods for decreasing player injury.