The Role of Large Language Models (LLMs) in Providing Triage for Maxillofacial Trauma Cases: A Preliminary Study

BACKGROUND

In the evolving field of maxillofacial surgery, integrating advanced technologies like Large Language Models (LLMs) into medical practices, especially for trauma triage, presents a promising yet largely unexplored potential. This study aimed to evaluate the feasibility of using LLMs for triaging complex maxillofacial trauma cases by comparing their performance against the expertise of a tertiary referral center.

METHODS

Utilizing a comprehensive review of patient records in a tertiary referral center over a year-long period, standardized prompts detailing patient demographics, injury characteristics, and medical histories were created. These prompts were used to assess the triage suggestions of ChatGPT 4.0 and Google GEMINI against the center's recommendations, supplemented by evaluating the AI's performance using the QAMAI and AIPI questionnaires.

RESULTS

The results in 10 cases of major maxillofacial trauma indicated moderate agreement rates between LLM recommendations and the referral center, with some variances in the suggestion of appropriate examinations (70% ChatGPT and 50% GEMINI) and treatment plans (60% ChatGPT and 45% GEMINI). Notably, the study found no statistically significant differences in several areas of the questionnaires, except in the diagnosis accuracy (GEMINI: 3.30, ChatGPT: 2.30; p = 0.032) and relevance of the recommendations (GEMINI: 2.90, ChatGPT: 3.50; p = 0.021). A Spearman correlation analysis highlighted significant correlations within the two questionnaires, specifically between the QAMAI total score and AIPI treatment scores (rho = 0.767, p = 0.010).

CONCLUSIONS

This exploratory investigation underscores the potential of LLMs in enhancing clinical decision making for maxillofacial trauma cases, indicating a need for further research to refine their application in healthcare settings.

Pattern and Management of Missile Injury to the Oral and Maxillofacial Region: A 12-Year Experience During Boko Haram Insurgency in Maiduguri, North-Eastern Nigeria

Introduction

Missile injury is a global public health problem, which occurs in both military and civilian settings. Boko Haram insurgency in North-Eastern Nigeria is one of the major violence the country experienced that resulted in many civilian casualties. This study was aimed at exploring the various patterns of the missile injuries to the maxillofacial region during Boko Haram insurgency.

Methods

In this retrospective cross-sectional study, relevant information was retrieved from patient records including sociodemographic, causes of missile injuries, site of injuries, pattern of presentation, treatment, and the complications, and analysed using SPSS version 23.

Result

A total of 526 patients with various maxillofacial injuries were seen during this 12-year study period, with age ranging from 4 to 65 years, the peak incidence in the age group 31-40 years, 89.5% were males, 92.9% of the injuries were allegedly inflicted by insurgents and comprised of 61.0% gunshot injuries, 24.5% bomb blast, and machete cuts 7.4%. Most of the injuries occurred in the lower third of the face, 39.8%, and mandible was the commonest fractured facial bone.

Conclusion

Facial injuries commonly are associated with devastating consequences to survivors and, hence, may require long time monitoring and psychosocial rehabilitations.

The effect of photobiomodulation therapy in common maxillofacial injuries: Current status

The use of photobiomodulation therapy (PBMT) may be used for treating trauma to the maxillofacial region. The effects of PBMT on maxillofacial injuries were discussed in this review article. The electronic databases Pubmed, Scopus, and Web of Science were thoroughly searched. This review included in vitro, in vivo, and clinical studies describing how PBMT can be used in maxillofacial tissue engineering and regenerative medicine. Some studies suggest that PBMT may offer a promising therapy for traumatic maxillofacial injuries because it can stimulate the differentiation and proliferation of various cells, including dental pulp cells and mesenchymal stem cells, enhancing bone regeneration and osseointegration. PBMT reduces pain and swelling after oral surgery and tooth extraction in human and animal models of maxillofacial injuries. Patients with temporomandibular disorders also benefit from PBMT in terms of reduced inflammation and symptoms. PBMT still has some limitations, such as the need for standardizing parameters. PBMT must also be evaluated further in randomized controlled trials in various maxillofacial injuries. As a result, PBMT offers a safe and noninvasive treatment option for patients suffering from traumatic maxillofacial injuries. PBMT still requires further research to establish its efficacy in clinical practice and determine the optimal parameters.

An Insight into the Present Pandemic Scenario (COVID-19) with Respect to Maxfac Speciality

The December 2019 pandemic killed about 2 million people and impacted countless more. SARS-CoV-2 causes COVID-19. The sickness causes dyspnea, high temperature, dry cough, loss of taste smell, etc., Due to the disease's fast spread, oral and maxillofacial surgical practices must be reconsidered. The World Health Organization, Association of Oral and Maxillofacial Surgeons of India, and other reputable bodies have released guidelines for safe and efficient COVID-19 therapy. This poll seeks surgeons' awareness of these worldwide and national bodies' guidance. A social media poll generated 173 replies, which were analyzed and interpreted. Many surgeons were aware of the recommendations and safety precautions, but others were unaware of the modifications in oral and maxillofacial surgery practice procedures.

Microfragmented Fat and Biphasic Calcium Phosphates for Alveolar Cleft Repair: Protocol for a Prospective, Nonblinded, First-in-Human Clinical Study

BACKGROUND

Biphasic calcium phosphates (BCP) may serve as off-the-shelf alternatives for iliac crest-derived autologous bone in alveolar cleft reconstructions. To add osteoinductivity to the osteoconductive BCPs to achieve similar regenerative capacity as autologous bone, a locally harvested buccal fat pad will be mechanically fractionated to generate microfragmented fat (MFAT), which has been shown to have high regenerative capacity due to high pericyte and mesenchymal stem cell content and a preserved perivascular niche.

OBJECTIVE

Our primary objectives will be to assess the feasibility and safety of the BCP-MFAT combination. The secondary objective will be efficacy, which will be evaluated using radiographic imaging and histological and histomorphometric evaluation of biopsies taken 6 months postoperatively, concomitant with dental implant placement.

METHODS

Eight patients with alveolar cleft (≥15 years) will be included in this prospective, nonblinded, first-in-human clinical study. MFAT will be prepared intraoperatively from the patient's own buccal fat pad. Regular blood tests and physical examinations will be conducted, and any adverse events (AEs) or serious EAs (SAEs) will be meticulously recorded. Radiographic imaging will be performed prior to surgery and at regular intervals after reconstruction of the alveolar cleft with the BCP-MFAT combination. Biopsies obtained after 6 months with a trephine drill used to prepare the implantation site will be assessed with histological and histomorphometric analyses after methylmethacrylate embedding and sectioning.

RESULTS

The primary outcome parameter will be safety after 6 months' follow-up, as monitored closely using possible occurrences of SAEs based on radiographic imaging, blood tests, and physical examinations. For efficacy, radiographic imaging will be used for clinical grading of the bone construct using the Bergland scale. In addition, bone parameters such as bone volume, osteoid volume, graft volume, and number of osteoclasts will be histomorphometrically quantified. Recruitment started in November 2019, and the trial is currently in the follow-up stage. This protocol's current version is 1.0, dated September 15, 2019.

CONCLUSIONS

In this first-in-human study, not only safety but also the histologically and radiographically assessed regenerative potential of the BCP-MFAT combination will be evaluated in an alveolar cleft model. When an SAE occurs, it will be concluded that the BCP-MFAT combination is not yet safe in the current setting. Regarding AEs, if they do not occur at a higher frequency than that in patients treated with standard care (autologous bone) or can be resolved by noninvasive conventional methods (eg, with analgesics or antibiotics), the BCP-MFAT combination will be considered safe. In all other cases, the BCP-MFAT combination will not yet be considered safe.

TRIAL REGISTRATION

Indonesia Clinical Trial Registry INA-EW74C1N; https://tinyurl.com/28tnrr64.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/42371.

Virtual surgical planning in craniomaxillofacial surgery: a structured review

Craniomaxillofacial (CMF) surgery is a challenging and very demanding field that involves the treatment of congenital and acquired conditions of the face and head. Due to the complexity of the head and facial region, various tools and techniques were developed and utilized to aid surgical procedures and optimize results. Virtual Surgical Planning (VSP) has revolutionized the way craniomaxillofacial surgeries are planned and executed. It uses 3D imaging computer software to visualize and simulate a surgical procedure. Numerous studies were published on the usage of VSP in craniomaxillofacial surgery. However, the researchers found inconsistency in the previous literature which prompted the development of this review. This paper aims to provide a comprehensive review of the findings of the studies by conducting an integrated approach to synthesize the literature related to the use of VSP in craniomaxillofacial surgery. Twenty-nine related articles were selected as a sample and synthesized thoroughly. These papers were grouped assigning to the four subdisciplines of craniomaxillofacial surgery: orthognathic surgery, reconstructive surgery, trauma surgery and implant surgery. The following variables - treatment time, the accuracy of VSP, clinical outcome, cost, and cost-effectiveness - were also examined. Results revealed that VSP offers advantages in craniomaxillofacial surgery over the traditional method in terms of duration, predictability and clinical outcomes. However, the cost aspect was not discussed in most papers. This structured literature review will thus provide current findings and trends and recommendations for future research on the usage of VSP in craniomaxillofacial surgery.

Design and development of a patient-specific temporomandibular joint implant: Probing the influence of bone condition on biomechanical response

Total temporomandibular joint (TMJ) replacement is widely recognized as an effective treatment for TMJ disorders. The long-term stability of TMJ implants depends on two important factors which are design concepts for fixation to anatomical locations in the mandible and bone conditions. Other factors include stress distribution, microstrain in the peri-implant, bone attributes like bone conditions leading to the clinical complications and failures. This study addresses these limitations by examining the influence of patient-specific design concepts and bone conditions on TMJ implant performance. Clinical evidences support the importance of implant design on healing ability. Previous studies have focused on achieving precise implant fit based on geometric considerations, however those published studies did not explore the impact of such. Against this perspective, the present study reports the extensive finite element analysis (FEA) results, while analyzing the impact of a newly designed patient-specific TMJ implant to address clinical complications associated with various bone conditions, particularly osteoporotic bone. In validating the FEA results, the performance of additively manufactured patient-specific TMJ implants was compared with designs resembling two commonly used clinically approved implant designs. By addressing the limitations of previous research and emphasizing the importance of bone conditions, the study provides valuable guidelines for the development of next-generation TMJ implants. These findings contribute to enhanced clinical outcomes and long-term success in the treatment of TMJ disorders.

Traumatic dental injuries sustained during Chile's civil unrest: A case series study

BACKGROUND/AIM

During Chile's period of social unrest, numerous people suffered physical trauma due to the use of police force. However, there have been no reports regarding traumatic dental injuries (TDIs) suffered in this context. This study aims to describe the dental trauma of patients injured by police during the social unrest period in Chile from 2019 to 2021.

MATERIAL AND METHODS

A case series methodology was employed. Following informed consent, clinical records of patients admitted to the Ocular and Dentomaxillofacial Prosthetic Care and Rehabilitation Program, who were affected by the violence of state agents during social mobilizations, were reviewed from October 2019 to December 2021. Information on the sociodemographic characteristics of the patients and the TDI diagnoses with their treatment needs were collected. A descriptive analysis was performed.

RESULTS

Forty-six patients were identified, nine of whom agreed to the informed consent. Most were male, with a mean age of 28 years, public health insurance, and a high educational level. The most common causes of injury were kinetic impact projectiles (KIPs) and the use of physical force (punches, kicks, or pushes). Of the nine cases described, 26 teeth were affected by TDI. The most affected teeth were the central upper incisors and, in most cases, they presented lesions in both injury categories: NA0D.0 (the tooth and pulp) and NA0D.1 (periodontal tissues). Treatment needs varied and included some complex procedures, such as implant-retained crowns and removable dental prostheses.

CONCLUSIONS

The use of force by police during the period of social unrest in Chile caused TDIs among demonstrators, which were mainly due to physical force from less-than-lethal weapons. Most cases presented injuries affecting the incisors with multiple teeth requiring complex treatments.

Custom-made ocular prosthesis: solitary method to improve facial aesthetics (a case report)

Loss of facial structures has a physical, social and psychological impact on affected individuals. Ocular trauma caused by assaults, falls, road traffic accidents, and household or work-related accidents may necessitate eye enucleation. Enucleation is also performed to treat severe infections of the eye, intraocular tumours and painful blind eyes. This procedure can result in post-enucleation socket syndrome with facial disfigurement and severely compromising facial aesthetics. Our patient complained of facial disfigurement because of a defect associated with the right eye. History and clinical features were suggestive of post-enucleation socket syndrome. The defect was rehabilitated with an ocular prosthesis. The rehabilitation procedure provided satisfactory results and a happy patient with good aesthetics. Maxillofacial prosthesis can restore and rehabilitate lost facial structures with artificial substitutes and helps in regaining patient´s natural appearance, the health of adjoining structures and subsequently, provide physical, social and psychological well-being.

Microwave Ablation for Refractory Giant Maxillofacial Arteriovenous Malformation: A Case Report

Maxillofacial arteriovenous malformation located in the sensitive parts of the nose and lips has been an arduous challenge for doctors to meet a balance between resection and aesthetics in one time. In this report, one patient with a giant arteriovenous malformation covering the forehead, the nose, the lip, and bilateral cheeks and resulting in the appearance of the face like a lion's face, can not meet satisfactory outcomes by other therapeutic methods. We successfully reduced the size of vascular lesion using low-power and short-duration microwave ablation under real-time ultrasound guidance. In the two-year follow-up, the patient's face almost recovered to normality. Microwave ablation is expected to be a new alternative therapy for the treatment of maxillofacial arteriovenous malformations. Laryngoscope, 133:2984-2987, 2023.

A meta-analysis to evaluate the prevalence of maxillofacial trauma caused by various etiologies among children and adolescents

AIMS

Children and adolescents who are affected by trauma may have complications that are more serious and dangerous. Herein, a meta-analysis to evaluate the prevalence of maxillofacial trauma caused by various etiologies according to the geographic regions of the world among children and adolescents was conducted.

MATERIALS AND METHODS

A comprehensive search was performed in four databases of PubMed/MEDLINE, Web of Science, Cochrane Library, and Scopus from January 1, 2006 until July 7, 2021. To evaluate the quality of included articles, an adapted version of the Newcastle-Ottawa scale was used. The prevalence of maxillofacial trauma was estimated by event rates and 95% confidence intervals in relation to etiology and geographic region of study population.

RESULTS

Through search in the databases and the electronic sources, 3071 records were identified, and 58 studies were eligible for inclusion in the meta-analysis. A total of 264,433 maxillofacial trauma cases were reported by all included studies. Globally, the overall prevalence of maxillofacial trauma was highest due to Road Traffic Crashes (RTC) (33.8%) followed by falls (20.7%), violence (9.9%), and sports (8.1%) in children/adolescents. The highest prevalence of maxillofacial trauma were observed in African population (48.3%) while trauma due to falls was most prevalent in Asian population (44.1%). Maxillofacial trauma due to violence (27.6%) and sports (13.3%) were highest in North Americans.

CONCLUSION

The findings demonstrate that RTC was the most prevalent etiology of maxillofacial trauma in the world. The prevalent causes of maxillofacial trauma differed between the regions of study population.

Macro, Micro, and Nano-Inspired Bioactive Polymeric Biomaterials in Therapeutic, and Regenerative Orofacial Applications

Introducing dental polymers has accelerated biotechnological research, advancing tissue engineering, biomaterials development, and drug delivery. Polymers have been utilized effectively in dentistry to build dentures and orthodontic equipment and are key components in the composition of numerous restorative materials. Furthermore, dental polymers have the potential to be employed for medication administration and tissue regeneration. To analyze the influence of polymer-based investigations on practical medical trials, it is required to evaluate the research undertaken in this sector. The present review aims to gather evidence on polymer applications in dental, oral, and maxillofacial reconstruction.

Protein Drug Delivery Using a Novel Maxillofacial Technique Targeting the Visual Pathway in the Brain, the Optic Nerve, and the Retina

Protein drugs are used for treating many diseases of the eye and the brain. The formidable blood neural barriers prevent the delivery of these drugs into the eye and the brain. Hence, there is a need for a protein drug delivery system to deliver large proteins across blood-neural barriers. Low half-life, poor penetration of epithelial barriers, low stability, and immunogenicity limit the use of non-invasive systemic routes for delivering proteins. In this pre-clinical study, the efficacy of a new maxillofacial route for administering protein drugs using a novel drug delivery system is compared with systemic administration through intra-peritoneal injection and ocular administration through topical eye drops and subconjunctival and intravitreal injections. Bevacizumab and retinoschisin proteins were administered using the maxillofacial technique along with systemic and ocular routes in wild-type male C57BL/6J mice. Liquid chromatography with tandem mass spectrometry and western blot was used to detect bevacizumab in tissue samples. Furthermore, immunohistochemistry was performed to detect the presence and localization of bevacizumab and retinoschisin in the retina and brain. The maxillofacial route of delivery could target the brain including regions involved in the visual pathway and optic nerve. The maxillofacial technique and intravitreal injection were effective in delivering the drugs into the retina. A new concept based on the glymphatic pathway, cerebrospinal fluid drug distribution, and the crossover of ipsilateral optic nerve fibers at optic chiasma is proposed to explain the presence of the drug in contralateral eye following maxillofacial administration and intravitreal injection.

Intraoral and maxillofacial abnormalities in patients with autosomal dominant hyper-IgE syndrome

Autosomal dominant hyper-IgE syndrome (AD-HIES) is an inborn error of immunity (IEI) caused by a dominant-negative mutation in the signal transducer and activator of transcription 3 (STAT 3). This disease is characterized by chronic eczematoid dermatitis, recurrent staphylococcal skin abscesses, pneumonia, pneumatoceles, and extremely high serum IgE levels. Loss-of-function STAT3 mutations may also result in distinct non-immunologic features such as dental, facial, skeletal, and vascular abnormalities, central nervous system malformations and an increased risk for bone fractures. Prophylactic treatment of Candida infections and prophylactic antimicrobial therapy for staphylococcal skin infections and sinopulmonary infections are essential. An awareness of the oral and maxillofacial features of HIES may facilitate early diagnosis with genetic counselling and may improve future patient care. This study describes oral, dental, and maxillofacial manifestations in 14 patients with genetically defined AD-HIES. We also review the literature and propose recommendations for the complex care of patients with this rare primary immunodeficiency.

Salivary biomarkers and temporomandibular disorders: A systematic review

Temporomandibular disorders (TMD) are a common condition affecting the musculoskeletal group evoking clinical signs such as pain, restricted mouth opening, and disability in the temporomandibular joint (TMJ), masticatory musculature, and the osseous structures in the surroundings. Saliva is a strong proponent of a diagnostic and prognostic tool for TMDs. Hence, a systematic review was undertaken to answer the research question "What is the role of salivary biomarkers in the identification of TMD?" A thorough literature search was performed in databases of PubMed, Embase, and Google Scholar till February 2022. Every included study was characterized by Study ID, location, sample size, demographic information, biomarker analysis, assessment method, and results. Newcastle-Ottawa scale was used to assess the methodological quality of all qualifying research. A total of eight articles were included for the review after screening the titles, abstracts, and full-text articles. The review included articles of observational design with a control group. TMD disorders were confirmed both clinically and radiographically in the study of Shoukri et al. TMDs are commonly prevalent in maxillofacial conditions. Despite the availability of various diagnostic techniques, certain limitations are remarkable. The researchers are yet to ascertain a gold standard biomarker to identify TMD.

External auditory canal injuries in maxillofacial trauma - Proposal of a symptom-based treatment algorithm with a report of twelve cases

Purpose

Injury to the external auditory canal (EAC) may occur following facial trauma. They manifest as otalgia, ear bleeding, otorrhea, facial palsy, or altered hearing. But literature regarding its management is sparse. The study aimed to identify the incidence and types of EAC injury in facial trauma, grade their severity, and propose a symptom-based treatment algorithm.

Patients and Methods

This was a prospective case series involving patients with signs/symptoms of EAC injury following maxillofacial trauma. The EAC was evaluated by clinical examination, imaging, endoscopy, and audiometry. Clinical findings were graded into mild, moderate, and severe. Treatment was matched to clinical findings according to the proposed algorithm. The outcomes of the study were incidence and types of EAC injury in facial trauma and resolution of presenting signs/symptoms. Data were analyzed for descriptive statistics using SPSS software (v26; IBM, Armonk, NY).

Results

A total of 88 patients reported with maxillofacial trauma during a 6-month period. Signs/symptoms of EAC injury were observed in 41 patients, of which 12 (11 males and 1 female) were confirmed with a diagnosis of EAC injuries. Eight patients demonstrated only cartilaginous injuries while three had bony injuries. Treatment was successful in 11 out of 12 patients, with a best point estimate of 0.86 (Z score-1.959, 95% CI).

Conclusion

Clinical findings of EAC injury mandate thorough investigation to ascertain the site and severity of the injury. Symptom-based treatment of EAC injuries produces an effective resolution of signs/symptoms and improved treatment outcomes.

Segmental (Central) Maxillectomy Using a Piezoelectric Surgery Unit in a Dog

Piezoelectric surgical units operate with a vibration in the range of 25 to 35 KHz, offering several advantages including high precision, selective cutting of bone while limiting damage to the surrounding soft tissues, less trauma to neurovascular tissues, reduced hemorrhage, and improved healing. Manual bone-cutting instruments operate at a high speed and can lead to thermal injury to the bone, severe damage to blood vessels, nerves, and soft tissues, and increased pain following bone surgery. This step-by-step manuscript describes the use of a piezoelectric surgical unit to perform a segmental (central) maxillectomy.

State of the Art in Temporomandibular Joint Arthrocentesis-A Systematic Review

Temporomandibular joint disorders are a heterogenic group of clinical conditions, which impair physiological functioning of the masticatory system. Arthrocentesis of the temporomandibular joint has become a widely approved method for non-invasive treatment, bridging the gap between conservative and surgical approaches. Regardless of technique, treatment is based upon joint lavage and lysis of the inflammatory fibrous tissue adhesions, which, in turn, improves joint mobility and reduces pain and closed lock. Recently, approaches for intra-articular injections have been proposed as adjuvant or replacement therapy. The aim of this study was to assess the most efficient technique of arthrocentesis. A systematic search based on PRISMA guidelines, including a computer search with specific keywords, a reference list search and a manual search, was performed. Relevant articles were selected after three search rounds for final review. The studies pulled for the analysis presented information about the relevant predictors, including the technique of arthrocentesis (single- or two-needle method), fluid used for lavage (Ringer lactate or saline), volume of the fluid, application of the injectable, number of interventions, pain (VAS) and mouth opening scores (MMO) and follow-up. All cohorts showed improvement in mouth opening, but significant pain reduction was observed only in cohorts treated either by arthrocentesis alone or arthrocentesis followed by intra-articular injectables. Intra-articular injectables used alone failed to reduce pain post-operatively when compared to other cohorts. We concluded that both double-needle and single-puncture arthrocentesis techniques are equally efficient. Application of the adjuvant injectable did not improve the outcomes of arthrocentesis performed alone. The volume of the fluid used for joint lavage and its chemical composition were not significant in clinical outcomes. However, due to the lack of homogeneity in the study settings, a meta-analysis could not be applied and a systematic review was conducted. We still, however, state that there is a knowledge gap in the current literature regarding the use of injectables alone, as well as a longitudinal follow-up, which provides information about treatment efficiency. More high-quality and randomized controlled trials are required to shed light on this subject.

The Use of Tactile Sensors in Oral and Maxillofacial Surgery: An Overview

BACKGROUND

This overview aimed to characterize the type, development, and use of haptic technologies for maxillofacial surgical purposes. The work aim is to summarize and evaluate current advantages, drawbacks, and design choices of presented technologies for each field of application in order to address and promote future research as well as to provide a global view of the issue.

METHODS

Relevant manuscripts were searched electronically through Scopus, MEDLINE/PubMed, and Cochrane Library databases until 1 November 2022.

RESULTS

After analyzing the available literature, 31 articles regarding tactile sensors and interfaces, sensorized tools, haptic technologies, and integrated platforms in oral and maxillofacial surgery have been included. Moreover, a quality rating is provided for each article following appropriate evaluation metrics.

DISCUSSION

Many efforts have been made to overcome the technological limits of computed assistant diagnosis, surgery, and teaching. Nonetheless, a research gap is evident between dental/maxillofacial surgery and other specialties such as endovascular, laparoscopic, and microsurgery; especially for what concerns electrical and optical-based sensors for instrumented tools and sensorized tools for contact forces detection. The application of existing technologies is mainly focused on digital simulation purposes, and the integration into Computer Assisted Surgery (CAS) is far from being widely actuated. Virtual reality, increasingly adopted in various fields of surgery (e.g., sino-nasal, traumatology, implantology) showed interesting results and has the potential to revolutionize teaching and learning. A major concern regarding the actual state of the art is the absence of randomized control trials and the prevalence of case reports, retrospective cohorts, and experimental studies. Nonetheless, as the research is fast growing, we can expect to see many developments be incorporated into maxillofacial surgery practice, after adequate evaluation by the scientific community.

Colour Stability of Two Commercially Available Maxillofacial Prosthetic Elastomers after Outdoor Weathering in Al Jouf Province

Facial prostheses are created from special elastomers modified for their specific physical and mechanical properties; however, they also show two common major clinical problems: gradual discolouration of the prosthesis over time in service environment and deterioration of static, dynamic, and physical properties. As a result of external environmental factors, facial prostheses may become discoloured and discolour by changing colour from intrinsic and extrinsic colouring, and this is associated with the intrinsic colour stability of elastomers and colourants. Thus, in this in vitro study, a comparative evaluation of the effect of outdoor weathering on the colour stability of A-103 and A-2000 room-temperature vulcanised silicones used for maxillofacial prosthesis was conducted. To accomplish this study, a total of 80 samples were fabricated, 40 samples of each material were grouped as clear (20) and pigmented (20). These samples were mounted on wooden board and the assembly was placed on the roof of the dental school from October 2021 to March 2022. To maximise the amount of sunlight on the specimens, the exposure rack was set on five 68° angles from horizontal and also to prevent standing water. The specimens were left uncovered during exposure. The testing of samples was conducted with the help of a spectrophotometer. The colour values were recorded in the CIELAB colour system. It describes the three colour coordinates (colour values) x, y, and z in three new reference values of L, a, and b, aiding in numerically classifying colour differences. After 2, 4, and 6 months of weathering, testing was conducted using a spectrophotometer and the colour change (ΔE) was calculated. The A-103 RTV silicone group with pigmentation showed the maximum change in colour after six months of environmental conditioning. The data for colour difference within groups were analysed using a one-way ANOVA test. Tukey's post hoc test assessed the pairwise mean comparison's contribution to the overall significant difference. The nonpigmented A-2000 RTV silicone group showed the maximum change in colour after six months of environmental conditioning. After 2, 4, and 6 months of environmental conditioning, pigmented A-2000 RTV silicone showed better colour stability than A-103 RTV silicone. The patients requiring facial prosthesis do need to work on outdoor fields, and thus weathering will have deleterious effects on such prosthesis. Hence, the selection of appropriate silicone material with respect to the Al Jouf province region is crucial, which includes economic, durable, and colour stability.

Synthesis of Novel Antimicrobial CHX-CaCl2 Coatings on Maxillofacial Fixatures for Infection Prevention

Maxillofacial surgery placement of fixatures (Leonard Buttons, LB) at close proximity to surgical incisions provides a potential reservoir as a secondary local factor to advanced periodontal disease, with bacterial formation around failed fixatures implicating plaque. To address infection rates, we aimed to surface coat LB and Titanium (Ti) discs using a novel form of chlorhexidine (CHX), CHX-CaCl₂ and 0.2% CHX digluconate mouthwash as a comparison. CHX-CaCl₂ coated, double-coated and mouthwash coated LB and Ti discs were transferred to 1 mL artificial saliva (AS) at specified time points, and UV-Visible spectroscopy (254 nm) was used to measure CHX release. The zone of inhibition (ZOI) was measured using collected aliquots against bacterial strains. Specimens were characterized using Energy Dispersive X-ray Spectroscopy (EDS), X-ray Diffraction (XRD) and Scanning Electron Microscopy (SEM). SEM displayed copious dendritic crystals on LB/ Ti disc surfaces. Drug release from double-coated CHX-CaCl₂ was 14 days (Ti discs) and 6 days (LB) above MIC, compared to the comparison group (20 min). The ZOI for the CHX-CaCl₂ coated groups was significantly different within groups (p < 0.05). CHX-CaCl₂ surface crystallization is a new drug technology for controlled and sustained CHX release; its antibacterial effectiveness makes this drug an ideal adjunct following clinical and surgical procedures to maintain oral hygiene and prevent surgical site infections.

E-scooters and maxillofacial fractures: a seven-year multi-centre retrospective review

BACKGROUND

Standing electric scooters (e-scooters) are a cost-effective and environmentally-friendly transport alternative, but also elicit substantial concern regarding associated craniofacial injuries. This study aims to describe the patient factors, procedural factors and post-operative outcomes of maxillofacial fractures caused by e-scooter accidents.

METHODS

Retrospective chart review of patients aged 18 years or older who were surgically treated for these injuries in 2014-2020 at two Australian tertiary hospitals.

RESULTS

There were 18 cases included. Most cases were male (66%). The mean age was 35 years. Common risk factors were alcohol use (86%) and lack of helmet use (62%). The most common fracture pattern was zygomatico-maxillary complex (ZMC) fractures (50%). There were no associated systemic injuries. Mean operation timing was 12 days post-injury for ZMC fractures and 3 days post-injury for condyle fractures. For ZMC fractures, the most common method of fixation was 2-point fixation (66%). For condyle fractures, the most common surgical approach was arch bars only (83%). Post-operative complications were reported in six cases, with malocclusion being the most common (n = 3). Revision surgeries were performed in two cases.

CONCLUSIONS

Maxillofacial fractures associated with e-scooter accidents appear to be increasing in incidence. Robust longitudinal evaluations with larger sample sizes are required to better understand associated presentations, surgical approaches and post-operative complications.

Infinitesimal Periangular Pterygomasseteric Transectioning Approach for the Base Fractures of the Mandibular Condyle: A Technical Note and Quality of Life Outcome

Purpose Infinitesimal Periangular Pterygomasseteric Transectioning Approach (IPPTA) is a minimal access surgical approach utilized for the management of base fractures of the mandibular condyle. The aim of the study was to evaluate and report the long-term post-operative functional outcome using this surgical access approach. Materials and method A prospective clinical study involving 20 patients was undertaken to evaluate the post-operative functional and aesthetic outcome for the patients that underwent surgery for base fractures of the mandibular condyle using IPPTA. The various parameters assessed were wound healing, marginal mandibular nerve injury, diet intake, mandibular function, and any other complications at twelfth post-operative month. Results IPPTA provided adequate exposure to the condylar base fracture for open reduction and internal fixation (ORIF) and was found to have an uneventful post-operative recovery phase in terms of functional and aesthetic outcomes. Conclusion IPPTA involves utilizing a smaller incision and provides adequate exposure to the condylar base region for ORIF to establish a satisfactory form and function with a predictable outcome.

Loosening of Teeth, an Unusual Presentation of Mucormycosis in COVID-19 Infected Patients

Aim of our study was to report unusual presentation of mucormycosis in patients, who were recovered from COVID-19 infection. This was a prospective observational study, undertaken at Ravindra Nath Tagore Medical College, Udaipur, India, over a period of last 3 months (April-June 2021). All patients with maxillofacial and dental mucormycosis were included in the study. All patients either have COVID-19 infection or recovered from it. Eight (40%) patients had history of use of corticosteroids for COVID1-19 infection, fifteen patients had either known case of diabetes or newly diagnosed diabetes with uncontrolled blood sugar at the time of presentation, three (15%) patients were in pre-diabetic state with HbA1c between 6.0 and 6.5% and two patients had no diabetes. None of patients had diabetic ketoacidosis and only one patient reported complete loss of vision with dental symptoms. There was unusual presentation of mucormycosis in form of loosening of teeth in uncontrolled diabetes. Injudicious use of steroids and uncontrolled diabetes are two main risk factors, so eyes should be kept on both of these.

Cosmetic Treatment Using Botulinum Toxin in the Oral and Maxillofacial Area: A Narrative Review of Esthetic Techniques

Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.

Choroidal Rupture in the Setting of Multi-Trauma

Herein the authors call attention to the importance of ophthalmic evaluation in the setting of multi-trauma, particularly with facial and orbital fractures. In institutions such as ours, a tertiary general hospital, where such fractures are initially managed by a non-ophthalmic team such as trauma or maxillofacial surgeons, we would advocate for prompt referral to the ophthalmology team for assessment as described by our case of a choroidal rupture in the setting of multi-trauma.

[Drug monitoring of the antibacterial drug Vancomycin in patients with purulent-inflammatory diseases of the maxillofacial region]

THE AIM OF THE STUDY

To evaluate the change in the level of concentration of the antibacterial drug Vancomycin registered in the purulent focus area (facial vein) and in the peripheral blood flow (cubital vein) in patients with phlegmon of the maxillofacial region (MFR).

MATERIALS AND METHODS

The clinical material of the study was 12 patients with phlegmon of MFR who were being treated in the maxillofacial department of the N.I. Pirogov State Clinical Hospital No. 1 of the Moscow Medical Center. The drainage of phlegmons was performed on the day of admission of the patient 2-3 days after the onset of the disease. The phlegmons involved two or more spaces of the MFR. As an antimicrobial drug, 500 mg of Vancomycin in 400 ml of saline solution was used intravenously. Quantitative registration of Vancomycin was carried out 2 hours after intravenous infusion. Blood sampling was carried out from the cubital and facial veins in an amount of 7-8 ml intraoperatively at the opening of the phlegmon, under endotracheal anesthesia. The concentration of the antibiotic was determined by high-performance liquid crystal chromatography.

RESULTS AND DISCUSSION

The study found that the concentration of Vancomycin in the facial vein exceeds similar indicators obtained from the cubital vein. The difference in the percentage ratio averaged 19.2±7.3%. In 10 patients with phlegmons of various localization, it was found that the penetration of the antibacterial drug into the tissues of the inflammatory focus is higher compared to the periphery. However, in a number of patients, the concentration of the drug did not exceed the minimum suppressive concentration recommended for obtaining a therapeutic effect (for Vancomycin, it is at least 2 mcg / ml).

CONCLUSION

To achieve the therapeutic effect of phlegmon treatment, it is necessary to select an individual dose of the drug for each patient.

Maxillofacial Horse Trauma: A 10-Year Retrospective Study at a UK Major Trauma Center

Introduction/Objecive

There are very few studies that have investigated equestrian-related maxillofacial injuries. A retrospective review was performed to investigate maxillofacial horse trauma at a Level 1 Trauma Centre at the Royal Stoke Hospital over the last 10 years between 2010 and 2020.

Study Design/Methods

Search of the hospital's major trauma database as well as ED records showed 51 patients who sustained maxillofacial injuries related to horses. Statistical analysis was performed using Chi Squared tests.

Results

41 patients were female and the remaining 10 were male. 43% of patients were female and aged 30 and under. Kicks from horses accounted for 64.4% of equine-related maxillofacial injuries. A total of 90 injuries were recorded. Hard tissue injuries which include all fractures accounted for 66.3% of injuries sustained. 70.5% patients sustained isolated maxillofacial trauma. There was an association between patients sustaining non-isolated maxillofacial trauma and hard tissue maxillofacial injuries (P = 0.04). 65.6% of injuries were managed operatively. Patients aged 30 and under were more likely to be managed operatively (P = 0.03).

Conclusion

Equestrian related maxillofacial trauma represents a proportion of trauma workload. The safety aspect of horse riding should be considered and education in safe riding and the use of appropriate safety equipment is vital.

Same-Admission Microvascular Maxillofacial Ballistic Trauma Reconstruction Using Virtual Surgical Planning: A Case Series and Systematic Review

Study Design

Retrospective case series; systematic review.

Objective

It is unknown whether the use of virtual surgical planning (VSP) to facilitate same-admission microsurgical reconstruction of the mandible following acute maxillofacial ballistic trauma (MBT) is sufficient to achieve definitive reconstruction and functional occlusion.

Methods

A single-center retrospective analysis was conducted for patients who underwent microsurgical reconstruction of the mandible using VSP after acute MBT. The PubMed/MEDLINE, Embase, ScienceDirect, and Scopus databases were systematically reviewed using blinded screening. Studies were evaluated via thematic analysis.

Results

Five patients were treated by same-admission and microsurgical reconstruction of the mandible using VSP. We observed an average of 16.4 ± 9.1 days between initial presentation and reconstruction, an average length of stay of 51.6 ± 17.9 days, 6.2 ± 2.8 operations, and 1.6 ± 0.9 free flaps per patient. Four types and 8 total flaps were employed, most commonly the anterior lateral thigh flap (37.5%). Care yielded complete flap survival. Each patient experienced at least 1 minor complication. All patients achieved centric occlusion, oral nutrition, and an approximation of their baseline facial aesthetic. Follow up was 191.0 ± 183.9 weeks. Systematic review produced 8 articles that adhered to inclusion criteria. Consensus themes in the literature were found for clinical goal and function of VSP when practicing MBT reconstruction, yet disagreement was found surrounding optimal treatment timeline.

Conclusions

Same-admission microsurgical reconstruction after MBT is safe and effective to re-establish mandibular form and function. VSP did not delay reconstruction, given the need for preparation prior to definitive reconstruction.

Anomalous chin lesion: The many presentations of extraosseous Ewing's sarcoma

Ewing's sarcoma (ES) is an aggressive, poorly differentiated round cell tumor in bone or soft tissues. This rare neoplasm is found primarily in the long bones of limbs and flat bone of pelvis with a predilection in the second decade in life. Primary ES of the maxillofacial region is exceptional and constitute 1% ± 4% of all cases. This case report is aimed at highlighting a very rare clinical presentation of extraosseous ES of the chin region-a first of its kind.

Epidemiology and Outcomes of Maxillofacial Injuries in NCAA Division I Athletes Participating in 13 Sports

Background:

Maxillofacial injuries account for an estimated 11% of National Collegiate Athletic Association (NCAA) sport-related injuries and occur at a rate of 0.2-1.5 injuries per 1000 athletic events/exposures.

Purpose:

The purpose of this study was to report the epidemiology, treatment, and outcomes of maxillofacial injuries in NCAA Division I athletes participating in 13 sports. It was hypothesized that the rate of maxillofacial injuries would be greater than previously reported in national registry studies.

Study Design:

Descriptive epidemiology study.

Methods:

A single-institution registry was utilized to retrieve the maxillofacial injuries and surgical procedures recorded over 4 athletic seasons, for the years 2015 through 2019, across 13 NCAA Division I sports. The incidence of injuries per sport was reported as the number per 1000 athlete-exposure (AE) hours. The time lost from participation and time to complete injury resolution per sport were reported as the mean and range.

Results:

A total of 193 maxillofacial injuries occurred over 4 seasons. The overall incidence of maxillofacial injuries was 2.06 injuries per 1000 AE hours. The injury incidence for male and female athletes was 1.92 and 2.43 injuries per 1000 AE hours, respectively. Men’s basketball (8.30 injuries per 1000 AE hours) and men’s water polo (8.15 injuries per 1000 AE hours) had the highest rates of all sports. Overall, 20 athletes (10.4%) required surgery. The mean time to resolution across all sports was 33.3 days (range, 0-336 days) per injury. The mean time lost across all sports was 17.1 days (range, 0-336 days) per injury.

Conclusion:

At a single NCAA Division I institution, maxillofacial injuries occurred at a higher rate than previously thought and could lead to significant time lost from sport participation. Basketball players were at the highest risk of this injury. Across all sports, male athletes took longer to return to sport after a maxillofacial injury compared to female athletes, but the latter required more time to fully recover. Maxillofacial injuries may require surgical treatment, and their prevention is critical.

Review of 173 Victims From a Level 1 Trauma Hospital in Najran, Kingdom of Saudi Arabia

Study Design

Studies on the concept of Damage Control Surgery (DCS) in the management of firearm injuries to the oral and maxillofacial region are still scarce, hence the basis for the current study.

Objectives

The objectives of the current study is to share our experience in the management of maxillofacial gunshot injuries with emphasis on DCS and early definitive surgery.

Methods

This was a retrospective study of combatant Yemeni patients with maxillofacial injuries who were transferred across the border from Yemen to Najran, Kingdom of Saudi Arabia. Demographics and etiology of injuries were stored. Paths of entry and exit of the projectiles were also noted. Also recorded were types of gunshot injury and treatment protocols adopted. Data was stored and analyzed using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp).

Results

A total of 408 victims, all males, were seen during the study period with 173 (42.4%) males sustaining gunshot injuries to the maxillofacial region. Their ages ranged from 21 to 56 years with mean ± SD (27.5 ± 7.6) years. One hundred and twenty-one (70.0%) victims had extraoral bullet entry, while 53 (30.0%) victims had intraoral entry route. Ocular injuries, consisting of 25 (14.5%) cases of ruptured globe and 6 (3.5%) cases of corneal injuries, were the most commonly associated injuries. A total of 78 (45.1%) hemodynamically unstable victims had DCS as the adopted treatment protocol while early definitive surgery was carried out in 47(27.2%) hemodynamically stable victims. ORIF was the treatment modality used for the fractures in 132 (76.3%) of the victims.

Conclusions

We observed that 42.4% of the war victims sustained gunshot injuries. DCS with ORIF was the main treatment protocol adopted in the management of the hemodynamically unstable patients.

A Nationwide Study of Skiing and Snowboarding-Related Facial Trauma

Study Design

Retrospective descriptive observational study.

Purpose

Skiing and snowboarding offers valuable opportunities for outdoor physical activity throughout the cold winter months, but these activities can result in substantial personally injury. This study aimed to analyze trends in skiing and snowboarding-related facial trauma epidemiology.

Methods

The National Electronic Injury Surveillance System (NEISS) was queried for facial trauma related to skiing and snowboarding treated in United States (US) emergency departments between 2010 and 2019. These data and weighted estimates were used to analyze patient demographics, injury location, and etiology.

Results

A total of 361 skiing or snowboarding-related facial injuries were recorded. Lacerations were most common injury (165/361; 45.7%), and facial fractures occurred in 21.6% (78/261) of patients. The most common facial fracture locations are the nose (38/78; 48.7%), orbit (17/78; 21.8%), and mandible (15/78; 19.2%). Pediatric patients accounted for 52% (187/361) of these injuries and had higher rates of lacerations (51.9% vs 39.1%, P < 0.05) and hospital admission (4.8% vs 1.15%, P < 0.05) than adults. Adults had a higher rate of facial fracture (30% vs 13.9%, P < 0.001) than children.

Conclusions

Skiing and snowboarding-related facial trauma is relatively uncommon in the US. In general, these injuries are largely decreasing, but facial fractures still occur not infrequently during these activities. Based on our data, we strongly urge helmet manufacturers to increase the availability of recreational snowsport helmets that include nose, orbit, and mandible protections, which could help to prevent many of these injuries.

Risk Factors for Infection of Sutured Maxillofacial Soft Tissue Injuries

Background: Maxillofacial soft tissue injuries (STIs) are common and frequent in emergency departments. The aim of this study was to analyze factors causing infection of maxillofacial STIs. Patients and Methods: Patients with maxillofacial STIs who received sutures and had complete medical records were evaluated. Gender, age, American Society of Anesthesiologists (ASA) grade, diabetes mellitus, wound age, wound length, wound contamination, wound type, and sites were analyzed using univariable analysis and binary logistic regression. Results: There were 3,276 cases included. In the univariable analysis, there was no significant difference in the infection rate between genders or between the wound age groups. In binary logistic regression, age, wound length, wound type, and physician level were risk factors for infection: age of 18-44 years (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.7-2.9), 44-64 years (OR, 3.1; 95% CI, 2.3-4.3), and ≥65 years (OR, 2.6; 95% CI, 1.7-4.1); wound length of 4-8 cm (OR, 1.7; 95% CI, 1.3-2.2) and >8 cm (OR, 2.4; 95% CI, 1.1-5.1); intra-oral wounds (OR, 1.6; 95% CI, 1.1-2.4) and communicating wounds (OR, 3.2; 95% CI, 2.3-4.4); junior specialists (OR, 1.6; 95% CI, 1.2-2.2); and lip (OR, 3.7; 95% CI, 1.1-12.0) and cheek (OR, 4.7; 95% CI, 2.3-17.1) sites. Wound contamination, ASA grade, and diabetes mellitus were not significantly different from wound infection in binary regression analysis. Conclusions: Age (>18 years old), wound length (>4 cm), intra-oral wounds, communicating wounds, suturing by junior surgeons, and lip or cheek injuries may be risk factors for maxillofacial STI infection. Even if the penetrating wound age exceeds 24 hours, it is meaningful to suture if there is no serious infection. For wounds at high risk of infection, further measures should be considered to reduce the possibility of infection, such as improving the surgical training of junior surgeons and improving the patient's wound care.

Protocol for Multi-Stage Treatment of Temporomandibular Joint Ankylosis in Children and Adolescents

Treatment of temporomandibular ankylosis is challenging and frequently leads to re-ankylosis, relapse, dangerous complications and, in turn, the need for multiple operations. In this article, we present a protocol for the treatment of ankylosis of the temporomandibular joints that assumes earlier intervention with the assistance of 3D virtual surgical planning (3DVSP) and custom biomaterials for better and safer surgical outcomes. Thirty-three patients were treated due to either uni- or bilateral temporomandibular ankylosis. Twenty individuals received temporomandibular prosthesis, whereas seventeen required simultaneous 3D virtual surgical/planned orthognathic surgery as the final correction of the malocclusion. All patients exhibited statistically significant improvements in mouth opening (from 1.21 ± 0.74 cm to 3.77 ± 0.46 cm) and increased physiological functioning of the mandible. Gap arthroplasty and aggressive rehabilitation prior to temporomandibular prosthesis (TMJP) placement were preferred over costochondral autografts. The use of 3DVSP and custom biomaterials enables more precise, efficient and safe procedures to be performed in the paediatric and adolescent population requiring treatment for temporomandibular ankylosis.

[Applications of cone beam computed tomography of the craneofacial structure in medical specialties. A review]

Cone-beam computed tomography (CBCT) of the craniofacial structure has demonstrated its usefulness in the dental area during the last decades, thus it has become a fundamental tool in the diagnosis, planning, and evaluation of treatment, and although it was not developed for the exclusive use in dentistry, as it is commonly considered, it is used in other areas such as medicine. It is specifically used in the head and neck area where different medical specialties interact, and at the same time these interact with dental specialties, so knowing the advantages of CBCT over different imaging technologies in the medical area is necessary. The purpose of this review was to describe the applications of observation, diagnosis, planning, and evolution of treatments using maxillofacial HSCT in different medical specialties. This work highlights the use of TCHC in different medical applications and highlights where it is most useful compared to other technologies.

Risk Factors for Failure of Hard Palate Mucoperiosteal Flap Repair of Acquired Oronasal Communication in Dogs: A Pilot Study

The objective of this retrospective pilot study was to describe potential risk factors for failure of hard palate mucoperiosteal flaps (HPF) transposed for closure of oronasal communication. Dogs (n = 28) with acquired oronasal communication defects were included in the study population. Functional success of an HPF was determined by visual inspection at the last examination and lack of clinical signs. Risk factors for HPF failure including age, sex, body weight, presence of neoplasia at the time of surgery, presence of neoplasia after surgery due to incomplete or narrow margins, use of CO₂ laser, previous surgeries in the same location, HPF blood supply, size of the HPF as a percentage of the total area of the hard palate mucoperiosteum, and distance traveled by the apex of the HPF were evaluated using descriptive statistics and unadjusted logistic regression modeling. Seven out of 28 (25%) hard palate flap procedures resulted in persistent oronasal communication and were considered failures. Body weight (Median: 17 vs. 25 kg, OR = 0.94, 80% CI = 0.90, 0.99), presence of neoplasia at the time of surgery (86 vs. 57%, OR = 4.50, 80% CI = 1.01, 20.06), HPF area (Median: 0.49 vs. 0.41, OR = 84.40, 80% CI = 1.66, 4,298) and apex travel distance (Median: 2.06 vs. 0.67, OR = 5.15, 80% CI = 2.14, 12.38) were associated with flap failure. Within this sample, the presence of neoplasia at the time of initial surgery, increasing the area of the HPF, and distance traveled by the HPF apex were associated with a greater odds of HPF failure. Further studies with larger sample sizes are needed to confirm repeatability of these results. HPFs remain a viable surgical option for closure of oronasal communication. Careful surgical planning, strict adherence to surgical principles, and awareness of anatomical limitations can increase the likelihood of success.

Diagnostic Accuracy of Ultrasonography for the Assessment of Maxillofacial Fractures: A Meta-analysis

Objective

To evaluate the pooled sensitivity and specificity of ultrasonography (USG) in maxillofacial fractures.

Materials and Methods

A systematic search was performed in five databases (PubMed, Scopus, CINAHL, Web of Science, Dentistry and Oral Sciences Source) from inception to September 12, 2020. Studies that reported or from which sensitivity and specificity can be calculated and studies published in the English language were included. Conference proceedings, letter to editors, and case reports were excluded. Screening of studies, data extraction, and risk of bias assessment (QUADAS -2) were done separately by two review authors. A bivariate random-effects model was used to calculate the pooled estimates.

Results

After the removal of duplicates, 1852 studies were included for screening of title and abstracts. Only 22 studies were included in the quantitative synthesis. The sample size ranged from 6 to 87. The majority of the studies assessed orbit and nasal bones fractures. Only two studies included a comprehensive assessment of facial fractures. The overall sensitivity and specificity values were 0.94 and 0.96, respectively.

Conclusion

USG has good diagnostic accuracy for the assessment of fractures of orbit and nasal bones. Clinicians need to consider the advantages and limitations of USG before recommending advanced imaging modalities.

Evaluation of Postoperative Sensory and Motor Deficit Following Craniomaxillofacial Reconstruction Using Bicoronal Flap: An Evaluative Study

Introduction:

The ideal surgical approach to treat craniomaxillofacial skeleton should provide maximum exposure of the facial skeleton, ensure less potential for injury to facial structures and allow for good cosmetic result. Several designs have been described such as hemicoronal, preauricular, lateral eyebrow, and bicoronal approach. Although the bicoronal flap gives superior long-term cosmetic results, it has a few disadvantages. We conducted this study to assess neurosensory disturbances and motor deficit following craniomaxillofacial reconstruction using bicoronal flap.

Materials and Methods:

A prospective study was carried out in the Department of Oral and Maxillofacial Surgery, North Karnataka, India. Forty patients with craniomaxillofacial trauma requiring fixation of fracture or reconstruction were included in the study. Postoperative neurosensory evaluation is carried out at intervals of 1 week, 1 month, 3 months, and 6 months clinically using mechanoreceptive and nociceptive testing.

Results:

Among 40 cases, 11 (27.5%) had postoperative paraesthesia affecting the supraorbital region; 9 (22.5%) of them had return of normal sensation within 6 months and 2 (5%) patients became normal after one year. Four patients had unilateral frontalis weakness on the right side for a period of 6 months.

Discussion:

The bicoronal flap is a preferred approach for access to the craniofacial skeleton and orbit with minimal sensory and motor complications. However, before choosing the same, the advantage of raising such a wide flap should be weighted comparing the benefits and complications.

Paediatric maxillofacial fractures in Ghana: Pattern, household cost, and distress

BACKGROUND

Maxillofacial fractures in the paediatric population are peculiar in risks, management, and potential complications.

AIM

To determine the pattern, psychological distress to parents, and economic cost of paediatric maxillofacial fractures in Ghana.

DESIGN

This study combined a retrospective evaluation with a cross-sectional cost-of-illness (COI) analysis to describe the pattern and economic cost of paediatric maxillofacial fractures in Ghana. The DASS 21 was used to assess psychological distress to parents. Descriptive summaries were generated, and cross-tabulations done, with consequent tests of associations.

RESULTS

In all, 253 patients were included in the study, with 68 households responding to the COI evaluation. Consisting of 179 (70.8%) males and 74 (29.2%) females, the ages ranged from 10 months to 17 years (mean age of 9.0 ± 5.0 years). Maxillofacial fractures frequently resulted from falls (56.5%), while traffic injuries accounted for 27.3%. The average household cost for paediatric maxillofacial fractures in Ghana was US$ 148.77, with the direct cost component accounting for 76% of this amount. At least half of the parents had some degree of psychological distress from the injury sustained.

CONCLUSION

Knowledge of the pattern and disease burden of maxillofacial fractures in children is vital in informing preventive strategies, especially for evolving health systems in sub-Saharan Africa.

Microbiological Characteristics and Surgical Management of Animal-Bite-Related Oral & Maxillofacial Injuries: A Single Center's Experience

The objective of the current study is to retrospectively evaluate animal-bite injuries and to gain insight into the epidemiology, accident consequences and treatment concept of these accidents in oral and maxillofacial surgery. Data of patients, who were admitted January 2015 and April 2021, were retrospectively evaluated regarding the patients’ characteristics (age, gender), facial distribution of substance defects/partial amputations, duration of hospitalization, operation treatments and antibiotic treatments. Data of 75 patients were included. Patients were bitten by dogs (n = 69.92%), cats (n = 4) and horses (n = 2). Lower eyelid/cheek complex was the most affected region (n = 37, 32.74%). Most of the patients between 0 and 3 years had to be operated on under general anesthesia (p = 0.011), while most of the adults could be operated on under local anesthesia (p = 0.007). In the age group 0–12 years, 30 patients (68%) were operated on under general anesthesia. Ampicillin/Sulbactam (48%) was the antibiotic most used. Antibiotics were adjusted after wound swabs in case of wound infections or critical wound conditions. This means that resistant antibiotics were stopped, and sensitive antibiotics were used. Structured surgical and antibiotic management of animal-bite wounds in the maxillofacial region is the most important factor for medical care to avoid long-term aesthetic consequences. Public health actions and policies under the leadership of an interdisciplinary committee could improve primary wound management, healing outcome and information status in the general population.

Retrospective Cohort Study of Frequency and Patterns of Orbital Injuries on Whole-Body CT with Maxillofacial Multi-Slice CT

Background: High-impact trauma frequently leads to injuries of the orbit, but literature focusing on the viscerocranium rather than the neurocranium is underrepresented. Methods: Retrospective cohort study (2006–2014) at an urban level 1 trauma center assessing the frequency and typical patterns of orbital injuries on whole-body computed tomography (WBCT) with maxillofacial multi-slice CT (MSCT) after severe trauma. (1) Screening of consecutive WBCT cases for dedicated maxillofacial MSCT. (2) Examination by two independent experts’ radiologists for (peri-/)orbital injuries. (3) Case review for trauma mechanisms. Results: 1061 WBCT were included revealing 250 (23.6%) patients with orbital injuries. Less than one-quarter (23.3%) of patients showed osseous and 9.5% showed soft tissue injuries. Combined osseous and soft tissue lesions were present in 39.2% of orbital injuries, isolated soft tissue injuries were rare. Single- or two-wall fractures of the orbit were prevalent, and the orbital floor was affected in 67% of fractures. Dislocated extraocular muscles (44.6%), deformation of the ocular globe (23.8%), and elongation of the optic nerve (12.9%) were the most frequently soft tissue findings. Vascular trauma was suspected in 15.8% of patients. Conclusions: Orbital trauma was confirmed in 23.6% of cases with suspected facial injuries after severe trauma. Concomitant soft tissue injuries should be excluded explicitly in cases with orbital fractures to prevent loss of vision or ocular motility.

Developing confidence in oral and maxillofacial dental core trainees: a national review of the trainee experience

This study considers the confidence of dental core trainees (DCTs) as they mature and progress through their first six months in an oral and maxillofacial surgery (OMFS) training post. Trainees have different incentives for embarking on a year in OMFS: to develop additional skills before settling into general dental practice; as a step towards specialty training; and to help decide about their career direction. Traditionally, an OMFS year has been associated with creating well-rounded and confident clinicians. We surveyed 123 DCTs at three stages over a six-month period to monitor their confidence in 10 clinical domains: assessing dentofacial infection, mandibular fractures, midface fractures, intraoral/extraoral swellings, airway risks, intraoral/extraoral lesions (benign/malignant), CT/MRI scans, and performing intraoral/extraoral suturing. The study demonstrates an increase in trainee confidence across all domains over the first six months of an OMFS post, with a particularly significant increase in the assessment of dentofacial infection, mandibular/midface fracture, and both intraoral and extraoral lesions and swellings.

Surgical excision of non-melanoma skin cancer: no end in site?

Non-melanoma skin cancer (NMSC) is the most common type of cancer in the UK and Ireland, accounting for approximately 20% of all new malignancies recorded, with evidence of increasing incidence. Surgical excision is regarded as the gold standard treatment for such lesions; however, incomplete excision incurs both physical and financial strain on patients and the healthcare service. Our aim is to identify which anatomical regions of the head and neck pose greater risk of incomplete excision and raise awareness for future surgical practice. Manual data collection was carried out on all patients admitted to the OMFS department for surgical excision of NMSCs between January 2016 and December 2017. Information collected included clinical notes and MDT outcomes. NMSCs excised via Mohs surgery. All tumours incompletely excised and requiring further treatment were noted with particular emphasis on the site of the lesion within the head and neck region, and the location of the positive margin on the specimen itself. A total of 506 NMSCs were excised (307 BCC, 199 SCC). Of these, 7.8% (n=24) and 6.0% (n=12), respectively, required further treatment due to incomplete excision. The incompletely exised lesions were predominately located on the nose (13.3%), temple (15.0%), and ear (12.8%). Our results demonstrate that our department is successfully excising NMSCs with minimal cases requiring further management. This study has identified anatomical profiles posing a higher risk of incomplete removal. Alongside the conventionally challenging sites of the nose and ear, we have highlighted additional risk within the temporal region. We therefore propose that Mohs surgery or a two-stage procedure should be considered as management for the temple at future MDTs.

Clinical negligence claims in oral and maxillofacial surgery over the last 10 years

According to NHS Resolution, the cost of harm from clinical activity in the last year was £8.3 billion. The steady increase in litigation within the National Health Service (NHS) has led to concerns being raised regarding the sustainability of the NHS, the increasing practice of defensive medicine, and the psychological impact on healthcare professionals. To our knowledge, litigation within oral and maxillofacial surgery has not been investigated in the UK since 2010, therefore our aims were to identify the trends within our specialty and the common reasons for negligence claims over the last 10 years. A freedom of information request was made to NHS Resolution for all clinical negligence claims from 2010 to 2020. A total of 1,122 claims were registered and the total for damages paid was £32,631,131. The claims were categorised by the primary injury and further divided into groups of cause codes. Four types of primary injury comprised 65.4% (n = 734) of all negligence claims and were as follows: additional or unnecessary operations (n = 313, 27.9%), unnecessary pain (n = 156, 13.9%), nerve damage (n = 139, 12.4%), and dental damage (n = 126, 11.2%). The damages associated with nerve damage were the costliest, with a total of £8,033,737 being paid. The significant increase in the number and cost of clinical negligence claims is concerning. The lessons from these claims must be shared and implemented to reduce the burden on the NHS, and ensure that we are providing a high quality of care with improved patient outcomes.

Locoregional Flap Reconstruction Following Oromaxillofacial Oncologic Surgery in Dogs and Cats: A Review and Decisional Algorithm

Primary treatment of most oromaxillofacial tumors in dogs and cats is resective surgery. Management of malignant tumors may be very challenging as wide/radical free-margin surgical removal must be achieved while preserving vital functions. Removal of orofacial tumors may result in large defects exposing the oral cavity or creating a communication with the nasal, pharyngeal, or orbital cavities. Such defects require orofacial reconstruction in order to restore respiratory and manducatory functions. The veterinary surgeon must be familiar with reconstructive techniques in order to prevent the inability of closing the defect, which could lead to an insufficient resection. Small oral defects exposing the nasal cavity are best closed with local random mucosal flaps. Closure of large oral defects may be better achieved with a facial or major palatine-based axial-pattern flap. Small to moderate facial defects can be closed with local advancement or transposition skin flaps. Reconstruction of large facial defects often requires the use of locoregional axial pattern flaps such as the caudal auricular, the superficial temporal, or the facial (angularis oris) myocutaneous axial pattern flaps. Recent publications have shown that the facial (angularis oris) flap is a very versatile and reliable flap in orofacial reconstructive surgery. A surgical decision algorithm based on the size, nature, and location of the defect is proposed.

Clinical management of squamous cell carcinoma of the tongue: patients not eligible for free flaps, a systematic review of the literature

INTRODUCTION

The management of squamous cell carcinoma (SCC) of the tongue represents the most demanding treatment planning in head and neck surgery. Ablation followed by free flap reconstruction is considered the gold standard, but not all patients are suitable for this strategy. The aim of this review is to provide a comprehensive view of surgical reconstruction possibilities in patients not eligible for free flaps.

METHODS

Following PRISMA recommendations, a systematic literature review was conducted searching for original papers that investigated outcomes of patients treated by surgical ablation for tongue SCC followed by reconstruction with local or pedicled flaps. Selected papers were read and data extracted for qualitative analysis.

RESULTS

Twenty articles met the inclusion/exclusion criteria. The study design was case series in sixteen papers, cohort study in the remaining four. Four different local flaps (BMM, FAMM, NLIF, SMIF) and four regional flaps have been discussed in included studies (IHF, SFIF, SCM, PMMC).

CONCLUSION

The improved anatomical knowledge makes local flaps a reliable alternative to free tissue transfer in cases requiring small-/medium-sized defects. Regional flaps still represent cornerstones in reconstruction of the tongue. Ease of execution, costs-to-benefit ratio, low-rate complications, minimal donor site morbidity represent the best advantages choosing local/regional flaps.

A case report of traumatic ulcerative granuloma with stromal eosinophilia (TUGSE) in a 21-year-old

We present an unusual case of a persistent solitary left palatoglossal ulcer with no history of trauma or associated risk factors. A TUGSE lesion, which mimics that of malignancy, must always be noted as a differential even in risk factor absence.