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.

The "Lumpy Jaw" Disease-Treatment and Diagnostical Challenge of Actinomycotic Osteomyelitis

Background

Osteomyelitis is a serious entity that can occur in many different locations. Especially in the mandible, osteomyelitis can show different clinical courses, which differ clearly from other anatomical regions in terms of severity and treatment. Osteomyelitis in the mandible is often caused by mixed species of the oral cavity. A species causing subacute/chronic osteomyelitis can be actinomyces. Actinomycotic osteomyelitis of the jaw represents a diagnostic and treatment challenging disease.

Conclusion

This article describes our perspective on the therapy pillars treating actinomycotic osteomyelitis. The rapid introduction of the two therapeutic elements (antibiosis/surgical therapy) is crucial regarding the outcome of this entity.

Temporalis Flap for Soft Palate Reconstruction - More than an Alternative for Patients Unsuitable for Microvascular Reconstructive Surgery

BACKGROUND/AIM

The treatment of squamous cell carcinoma (SCC) in the oral cavity for operable patients usually consists of surgical tumor resection, unilateral or bilateral neck dissection and defect reconstruction. In addition to local flaps, multiple, particularly microsurgical, distant flaps have been developed, which are mainly considered state of the art reconstruction. However, depending on previous operations and individual patient factors, microsurgical reconstruction is sometimes not suitable.

CASE REPORT

A 54-year-old male presented to the Department of Oral and Maxillofacial Surgery with leukoplakia-like changes in the area of the soft palate. Radiological and histopathological findings revealed SCC of the soft palate. Due to the patient's reduced general condition, pronounced vasosclerosis and the patient's negative opinion towards microsurgical reconstruction, the indication for tumor resection with simultaneous temporalis flap reconstruction was made. The temporalis flap showed sufficient healing throughout the follow up.

CONCLUSION

For patients who are unsuitable for microsurgery (previous operations, radiation, patient's request), well-known local flaps such as the temporalis flap represent more than an alternative treatment for defect reconstruction. The temporalis flap is particularly suitable for defect reconstruction of the maxilla and palate due to its easy flap raising and low complication rates. This case report shows the step-by-step flap raising of temporalis flap for soft palate reconstruction.

Risk factor analysis for perioperative complications in impacted third molar surgery - a single center experience

BACKGROUND

The surgical removal of impacted third molars is usually carried out by an oral/maxillofacial surgeon. Two specific risks of surgical removal of impacted third molars are oroantral communication (OAC) when extracting ​​upper third molars and hypesthesia of the inferior alveolar nerve (IAN) ​​when extracting lower third molars. The aim of this study is to determine the distribution of complications in deeply impacted third molar surgery, to identify specific risk factors influencing the most common perioperative (OAC, IAN hypesthesia) and to compare these results with other studies.

MATERIALS AND METHODS

The clinical findings, digital panoramic radiographs, intra- and postoperative data of 80 patients with a total of 232 impacted third molars that had been subjected for tooth extraction, from December 2022 and August 2023, were collected and analyzed. Perioperative complications (IAN hypesthesia, OAC, hypesthesia lingual nerve, postoperative bleeding, postoperative infection) were identified. A risk analysis for OAC and IAN hypesthesia was performed regarding perioperative data.

RESULTS

Overall, the rate of OAC for the right upper third molar was 12.8% and for the left upper third molar 15.6%. The complication rates regarding transient hypesthesia were 8.1% for the left IAN and 7.3% for the right IAN. The distance to maxillary sinus, the depth score according to Pell and Gregory, the bone coverage score, the operation time, the tooth's angulation and the type of surgeon (oral surgeon, DMD) were identified as significant risk factors for the occurrence of OAC. The minimum distance to IAN, the bone coverage score, the total operation time and the operation by an oral surgeon (DMD) were identified as significant risk factors for hypesthesia of the IAN.

CONCLUSION

Next to the risk factors from above, the present study is one of the first showing that patients who were primarily operated on by an oral surgeon (DMD) and not a maxillofacial surgeon (MD, DMD) showed higher rates of OAC and IAN hypesthesia in impacted third molar extraction. The results of this study can serve as a baseline for further studies to investigate complication patterns in impacted third molar surgery.

Distribution and impaction patterns of third molars in a sample of German population: Retrospective analysis in a high turnover maxillofacial department

BACKGROUND

The surgical removal of impacted third molars is considered a routine procedure for oral and maxillofacial surgeons. However, the distribution of impacted molars varies among different populations. A study into impaction patterns in the German population is currently not described. The aim of this retrospective study is to determine patterns of impacted third molars in a sample of German population, to identify gender and age specific differences as well as further risk factors for impacted molar extraction and to compare these results with other studies.

MATERIALS AND METHODS

The clinical findings and digital panoramic radiographs of 84 patients with a total of 243 impacted third molars that had been subjected for tooth extraction, from January to September 2023, were collected and analyzed. All third molars were analyzed according to Winter´s angulation, Pell and Gregory Score of depth and relationship to ramus. Furthermore, inferior alveolar nerve and maxillary sinus proximity were identified through a newly developed risk score and an analysis of patient´s gender and age regarding impaction patterns was performed.

RESULTS

No significant gender specific differences were found regarding the impaction patterns. Third molar angulations significantly differed regarding patient´s age (cut-off 26 years). In comparison, third molar depth, bone coverage, nerve approximity and angulation patterns differed from the results of other populations.

CONCLUSION

The results of this study can serve as a baseline for further studies of third molar impactions in the German population to minimize perioperative complications in impacted third molar surgery.

Septic Cervicofacial Phlegmon Following Basal Cell Carcinoma Excision: Life-threatening Complication of Routine Operation in Maxillofacial Surgery?

Background/Aim

Basal cell carcinoma (BCC) is a frequent tumor entity, especially in the facial region. The standard therapy for BCC is surgical tumor excision which is generally a low-risk procedure. One of the life-threatening surgical risks and complications when removing BCC in the facial area is infection with the possibility to spread across the deep neck spaces as well as systemic inflammation (sepsis).

Case Report

A 73-year-old patient presented to the emergency department with a swelling of the right cheek, extended towards the neck. Based on his medical history, an outpatient BCC excision of the cheek had been performed the day before. Laboratory tests showed a fulminant inflammatory process of sepsis. Computed tomography (CT) revealed a buccal phlegmon on the right extended towards the deep neck. A diagnosis of septic cervicofacial phlegmon following BCC excision was made. The therapy consisted of intensive care sepsis treatment, surgical relief, and drainage of the phlegmon and a calculated antibiotic treatment (piperacillin/tazobactam, clindamycin).

Conclusion

Removal of BCC in the facial region is generally a low-risk procedure. A possible complication is postoperative wound infection. In rare cases the clinical picture of a septic cervicofacial phlegmon can develop. Surgical focus sanitation, broad-based antibiotic therapy and intensive care sepsis management are the key therapeutic pillars of this postoperative complication.

Treatment Challenges in Soft Tissue Reconstruction in Patients With MRONJ - The Nasolabial Flap

BACKGROUND/AIM

Antiresorptive drugs (e.g., bisphosphonates, denosumab) are crucial in the treatment of oncological diseases. However, these antiresorptive drugs can cause medication-related osteonecrosis of the jaw (MRONJ). MRONJ is a challenging disease regarding the soft tissue defect treatment. There are various surgical reconstruction techniques. One of them is the nasolabial flap.

CASE REPORT

The present case report describes a 76-year-old female suffering from MRONJ leading to a progressive abscess of the mandible as well as an intra/extraoral fistula with extent to the chin region. Surgical splitting of the abscess was performed immediately. In the further course, a surgical decortication of the mandible with soft tissue defect treatment using a mucoperiosteal flap was performed. Intraoperatively, the bone of the mandible showed severe necrotic defects in multiple locations. Therefore, a continuity resection of the mandible with an insertion of a reconstruction plate was performed. Postoperatively, however, there was a progressive wound dehiscence. Due to the persisting regression of the gingival mucosa, the soft tissue defect was treated with a caudally pedicled bilateral nasolabial flap. The further clinical follow-up showed no recurrence of MRONJ with a well-healed nasolabial flap.

CONCLUSION

In addition to mucoperiosteal flaps and microvascular reconstructions, the nasolabial flap can be a sufficient surgical therapy for intraoral soft tissue defect reconstruction.

Subacute Actinomycotic Osteomyelitis of the Mandible - An Underreported Disease?

BACKGROUND/AIM

Cervicofacial actinomycosis is a rare entity. The manifestation of this disease in the context of osteomyelitis in the mandible is even rarer.

CASE REPORT

This case report describes a 70-year-old female with a painful swelling in the left mandible. The swelling was initially noticed four weeks ago. Furthermore, the patient reported problems with medications concerning her type II diabetes mellitus. Due to multiple decayed teeth, the patient had multiple teeth extracted in recent years, including teeth 36-38 in the left mandible. Orthopantogram (OPG) and computed tomography (CT) scan showed an unspecific osteolysis in the left mandible. An incisional biopsy was performed revealing subacute necrotizing osteomyelitis of the mandible due to actinomyces. Furthermore, the patient was treated with open debridement, curettage, and decortication as well as long term antibiotics (amoxicillin + clavulanic acid) for 6 weeks. In addition, type II diabetes mellitus could be controlled with various medications (Metformin, Dapagliflozin). Clinical follow-up revealed no evidence of recurrence.

CONCLUSION

Even though actinomycosis is rare, it should be included in the differential diagnosis of unspecific osteomyelitis of the jaw. Antibiotics and surgical decortication are the crucial therapy pillars when treating actinomycotic osteomyelitis in the mandible.

Chronic Maxillary Sinusitis Caused by an Aspergilloma in the Context of Inadequately Treated Type II Diabetes Mellitus

BACKGROUND/AIM

The prevalence of chronic sinusitis (CS) in Europe is greater than 10%. The causes of CS are diverse. In some cases, dental treatment in the maxilla as well as fungal infection, such as aspergilloma, can lead to CS. Inadequately treated illnesses, such as type II diabetes, are known risk factors for atypical infections.

CASE REPORT

The present case report describes a 72-year-old female suffering from CS in the maxillary sinus. A few years earlier, the patient received endodontic treatment of a maxillary tooth. For further diagnostics a CT-scan was performed showing an obstructed maxillary sinus on the left due to a polypoid tumor. The patient had been suffering from type II diabetes that had been inadequately treated for several years. The patient was surgically treated with an osteoplasty of the maxillary sinus combined with a supraturbinal antrostomy. Histopathological findings revealed an aspergilloma. The surgical therapy was supplemented by antimycotic therapy. In addition, the patient received antidiabetic treatment leading towards stable blood sugar levels.

CONCLUSION

Rare entities, such as aspergillomas, can also be the cause of CS. In particular, patients with previous illnesses relevant to the immune system are predisposed for Aspergilloma after dental treatment leading to CS.

Giant Cell Angiofibroma in the Buccal Mucosa - A Rising Entity?

BACKGROUND

Tumors of the oral cavity must be differentiated into benign and malignant. Rare tumors must also be considered throughout the differential diagnosis when dealing with pathologic changes in the oral mucosa. Examples of rare benign tumors within the oral cavity are solitary fibrous tumors (SFTs). In recent years, individual case reports of SFTs in the oral cavity have been published showing a rising incidence of this rare entity.

CASE REPORT

The present case report describes the occurrence of a subtype of SFT in the right buccal mucosa, the so-called giant cell angiofibroma (GCA). Histopathologically, GCA are distinguishable from SFT (NOS) by pseudovascular spaces lined by multinucleated giant cells. GCA generally shows a benign tumor behavior. The treatment of choice was surgical excision through an intraoral approach.

CONCLUSION

To the best of our knowledge, this is one of a few reports of GCA arising in the buccal mucosa.

Fulminant Adenoid Cystic Carcinoma of the Maxillary Sinus - A Rare Finding: Case Report

BACKGROUND

The most common malignant tumor of the small salivary glands in the head and neck region is adenoid cystic carcinoma (ACK). The most common localization of ACK is the hard palate. ACK does not show any sex predisposition and is mainly diagnosed in middle-aged patients.

CASE REPORT

The present case report describes a fulminant ACK in the rare localization of maxillary sinus in a 36-year old male. The subsequent surgical treatment consisted of a radical hemimaxillectomy using an extraoral approach according to Weber-Fergusson-Dieffenbach and ipsilateral neck dissection. A magnetic epithesis was used for initial defect coverage of the maxillary bone accompanied by an obturator prosthesis. The surgical treatment was then followed by adjuvant proton therapy.

CONCLUSION

This case report shows how individual patient care can be provided according to the latest therapy standards of ACK in the rare localization of the maxillary sinus.

Metastasis of a Solitary Fibrous Tumor in the Mandible: A Case Report

BACKGROUND/AIM

The solitary fibrous tumor (SFT) is a mesenchymal neoplasm and belongs to the group of soft tissue sarcomas. The SFT is characterized by indolent, slowly progressive growth and manifests itself clinically by compression of neighboring structures. The treatment of choice is surgical removal of the tumor. In advanced stages, there is also the possibility of chemotherapy, systemic therapy, or immunotherapy, as well as radiotherapy. Depending on their location and severity, SFTs show different recurrence rates and survival functions.

CASE REPORT

The present case report shows an extremely rare localization of a low-risk SFT in the floor of the mouth. Despite complete surgical removal of the SFT, the patient showed a metastasis of the SFT in the mandible two years postoperatively. Therefore, this case report shows that even a low-risk SFT in the localized stage can metastasize despite of total surgical removal. Consequently, SFTs of the head and neck region require close clinical and imaging follow-up.

CONCLUSION

Although the localization of the SFT in the oral cavity is a rarity, this entity should be included in the differential diagnosis in the case of long-term space-occupying processes in the head and neck region. This report is the first regarding metastasis of a SFT to the mandible.

Predicting clinical outcome by indexed mitral valve tenting in functional mitral valve regurgitation

OBJECTIVES

Mitral valve (MV) tenting parameters are indicators of left ventricular remodelling severity and may predict outcome in functional mitral regurgitation (FMR). We hypothesised that indexing of MV tenting area to body surface area (BSA), to mitral annulus diameter or gender-adjusted analysis of tenting parameters may improve their prognostic value.

METHODS

We identified retrospectively 240 patients with consecutive FMR (mean age 68±10 years; men=135) from our institutional database who underwent isolated MV annuloplasty during a period of 7 years (2010-2016). Using preoperative two-dimensional transthoracic echocardiographic images, MV tenting parameters including tenting area, tenting height and annulus diameter were systematically assessed. Follow-up protocol consisted of chart review and structured clinical questionnaire. Primary study endpoint was the composite of death and adverse cardiac events (ie, MV reoperation, cardiac resynchronisation therapy implantation, ventricular assist device implantation or heart transplantation).

RESULTS

BSA-indexed MV tenting area was identified as independent predictor of primary study endpoint (HR 1.9; 95% CI 1.1 to 3.5; p=0.02). After cut-off point analysis, BSA-indexed MV tenting area >1.35 cm²/m² was significantly associated with primary study outcome (HR 2.3; 95% CI 1.3 to 4.0; p=0.003). Annulus-indexed MV tenting area showed only a tendency towards primary study endpoint prediction (HR 2.8; 95% CI 0.6 to 12.6; p=0.17). Between female and male patients, BSA-indexed MV tenting area was similar (1.42±0.4 cm²/m² vs 1.45±0.4cm²/cm²; p=0.6) and gender was not associated with primary study outcome (HR 0.8; 95% CI 0.5 to 1.4; p=0.5).

CONCLUSION

In our FMR cohort, BSA-indexed MV tenting area showed the strongest association with negative outcomes following isolated MV annuloplasty. Patients with BSA-indexed MV tenting area >1.35cm²/m² could potentially benefit from additional surgical maneuvers addressing left ventricular remodelling.

Prognostic value of mitral valve tenting area in patients with functional mitral regurgitation

OBJECTIVES

Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters.

METHODS

We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010-2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data.

RESULTS

A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan-Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area <2.4 cm2 (n = 87) (65.3 ± 5.5% vs 77.1 ± 6.3%; P = 0.06).

CONCLUSIONS

MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.