An 11-year multicentric surgical experience on pediatric orbital floor trapdoor fracture: A World Oral Maxillofacial Trauma (WORMAT) project.

INTRODUCTION: Trapdoor fractures of the orbital floor occur almost exclusively in the paediatric population. Despite being widely discussed in the literature, their management remains controversial. The objective of this retrospective study was to analyse the surgical experiences on paediatric trapdoor fractures in the maxillofacial centres participating in the WORMAT project. MATERIALS AND METHODS: 14 centres collected data for patients aged ≤16 years operated between January 2011 and December 2022. The demographic, cause and type of fracture, timing from injury to surgery, surgical approach, type of floor repair and outcomes were recorded. Diplopia, surgical wound infection, hardware loosening and dysesthesia in the infraorbital nerve area were recorded at follow-up. RESULTS: 43 patients were included: 25 children (0-12 y) and 18 adolescents (13-16 y) (mean age, 11.1 years). Surgical treatment was performed within 24 h in 51 % of the patients, within 24-72 h in 33 %, and beyond 72 h in the remaining. The orbital floor was repaired with a resorbable implant/membrane in 63 % of the patients, open reduction without an implant in 30 %, a titanium mesh implant in 3 adolescent patients. At follow-up (mean 16.3 months), 14 patients had residual diplopia in the upper fields, only two of these resolved within 6 months. DISCUSSION: A tendency toward an increased incidence of postoperative diplopia with longer intervals between trauma and surgery was observed. This study showed different choices regarding the material placed on the floor, with a preference for open reduction without implants in children, compared to the use of resorbable implants or membranes in adolescents.

Policy of fourteen maxillofacial divisions towards titanium plates removal after internal fixation of paediatric maxillofacial fractures: A World Oral Maxillofacial Trauma (WORMAT) project.

INTRODUCTION: The aim of this 11-year retrospective multicentric study is to evaluate the policy of 14 maxillofacial surgery divisions in terms of titanium plate removal from paediatric patients who had undergone open reduction and internal fixation (ORIF) to treat maxillofacial fractures. MATERIAL AND METHODS: Patients ≤ 16 years undergoing surgical treatment for fractures of middle and lower third of the face between January 2011 and December 2022, with a minimum follow-up of 6 months, were included. Age (group A: ≤ 6 years, B: 7-12 years, C: 13-16 years), sex, fracture location and type, surgical approach, number, and location of positioned and removed plates, timing and indications for removal were recorded. RESULTS: 191/383 (50 %) patients (median age, 10 years; M:F ratio 2.1:1) underwent removal of 319/708 (45 %) plates. Maxillary dentoalveolar process (91 %), angle/ramus (63 %) and mandibular body (61 %) had a significantly higher removal rate than other fracture sites (p < 0.001). A significant decreasing trend in removal with increasing age was observed, from 83 % in Group A to 24 % in Group C (p < 0.001). On the total of positioned plates, 11 % were removed for symptomatic reasons (5 % infections, 6 % discomfort/pain) and 34 % for other reasons (28 % scheduled removal). DISCUSSION: This multicentric study showed that plate removal was not performed routinely in the paediatric population. The incidence and causes of symptomatic plates removal were consistent with the literature, while the plate removal rate from asymptomatic patients was lower. A correlation was found between increasing age and a reduction in the frequency of plate removal procedures.

Open reduction and internal fixation of paediatric maxillozygomatic complex fractures: An 11-year multicentric retrospective study.

BACKGROUND/AIM: Paediatric maxillozygomatic complex (MZC) fractures are uncommon, and there is a scarcity of data regarding their surgical treatment. The aim of this study was to analyse choices and outcomes of open reduction and internal fixation (ORIF) for MZC fractures among 14 maxillofacial centers around the world. MATERIALS AND METHODS: This multicentric retrospective observational study included patients ≤16 years of age with quadripod MZC fractures treated with ORIF from January 2011 and December 2022. The following data were collected: age, gender, dentition stage (deciduous, mixed, and permanent), cause of injury, type of fracture, surgical approach, site of osteosynthesis (infraorbital rim, zygomaticomaxillary buttress, frontozygomatic, and zygomaticotemporal sutures), material (titanium or resorbable) and number of plates used, and outcome. The minimum follow-up was 6 months. Statistical analyses were performed with Fisher's exact test or chi-squared test, as appropriate. RESULTS: Sixty-four patients (mean age, 12.3 years) with quadripod MZC fractures were included. Seventy-two percent of patients received a single-point fixation. The zygomaticomaxillary buttress was the most common site for fixation, both in single-point and two-point fixation schemes, especially in combination with the frontozygomatic suture. Increasing age was associated with a higher rate of plate removal (p < .001). Postoperative complications included 5 (7.8%) cases of wound infections, 2 (3.1%) infraorbital paraesthesia, 1 (1.6%) ectropion. Residual facial asymmetry was found in 5 (7.8%) patients and was not associated with the type of fixation (p > .05). CONCLUSIONS: This study highlights the possibility of using ORIF, even with a single point of fixation, for the treatment of displaced quadripod MZC fractures in the paediatric population. The zygomaticomaxillary buttress was the preferred site of fixation and allowed for adequate stabilization with no external scars and a low risk of tooth damage. Future prospective studies with long-term follow-up are needed to establish definitive surgical protocols and clarify the surgical decision-making.

Current Strategies for Treatment of Mandibular Fractures With Plate Osteosynthesis: A European Prospective Study.

PURPOSE: The training and preferences of surgeons influence the type of surgical treatment for mandibular fractures. This multicentre prospective study analyzed the current treatment strategies and outcomes for mandibular fractures with open reduction and internal fixation (ORIF). MATERIAL AND METHODS: This prospective study included patients aged ≥16 years who underwent ORIF for mandibular fractures in 12 European maxillofacial centers. Age, sex, pretrauma dental status, fracture cause, site and type, associated facial fractures, surgical approach, plate number and thickness (≤1.4 or ≥1.5 mm), duration of postoperative maxillomandibular fixation, occlusal and infective complications at 6 weeks and 3 months, and revision surgeries were recorded. RESULTS: Between May 1, 2021 and April 30, 2022, 425 patients (194 single, 182 double, and 49 triple mandibular fractures) underwent ORIF for 1 or more fractures. Rigid osteosynthesis was performed for 74% of fractures and was significantly associated with displaced ( P =0.01) and comminuted ( P =0.03) fractures and with the number of nonsurgically treated fracture sites ( P =0.002). The angle was the only site associated with nonrigid osteosynthesis ( P <0.001). Malocclusions (5.6%) and infective complications (5.4%) were not associated with osteosynthesis type. CONCLUSION: Rigid osteosynthesis was the most frequently performed treatment at all fracture sites, except the mandibular angle, and was significantly associated with displaced and comminuted fractures and the number of nonsurgically treated fracture sites. No significant differences were observed regarding postoperative malocclusion or infections among osteosynthesis types.

Manual versus rigid intraoperative maxillo-mandibular fixation in the surgical management of mandibular fractures: A European prospective analysis.

PURPOSE: Intraoperative stabilisation of bony fragments with maxillo-mandibular fixation (MMF) is an essential step in the surgical treatment of mandibular fractures that are treated with open reduction and internal fixation (ORIF). The MMF can be performed with or without wire-based methods, rigid or manual MMF, respectively. The aim of this study was to compare the use of manual versus rigid MMF, in terms of occlusal outcomes and infective complications. MATERIALS AND METHODS: This multi-centric prospective study involved 12 European maxillofacial centres and included adult patients (age ≥16 years) with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate or partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, modality of intraoperative MMF (manual or rigid), outcome (minor/major malocclusions and infective complications) and revision surgeries. The main outcome was malocclusion at 6 weeks after surgery. RESULTS: Between May 1, 2021 and April 30, 2022, 319 patients-257 males and 62 females (median age, 28 years)-with mandibular fractures (185 single, 116 double and 18 triple fractures) were hospitalised and treated with ORIF. Intraoperative MMF was performed manually on 112 (35%) patients and with rigid MMF on 207 (65%) patients. The study variables did not differ significantly between the two groups, except for age. Minor occlusion disturbances were observed in 4 (3.6%) patients in the manual MMF group and in 10 (4.8%) patients in the rigid MMF group (p > .05). In the rigid MMF group, only one case of major malocclusion required a revision surgery. Infective complications involved 3.6% and 5.8% of patients in the manual and rigid MMF group, respectively (p > .05). CONCLUSION: Intraoperative MMF was performed manually in nearly one third of the patients, with wide variability among the centres and no difference observed in terms of number, site and displacement of fractures. No significant difference was found in terms of postoperative malocclusion among patients treated with manual or rigid MMF. This suggests that both techniques were equally effective in providing intraoperative MMF.

European multicenter prospective analysis of the use of maxillomandibular fixation for mandibular fractures treated with open reduction and internal fixation.

INTRODUCTION: The goal of mandibular fracture treatment is to restore static and dynamic occlusal functions. Open reduction and internal fixation (ORIF) of these fractures can be associated with an intraoperative and/or postoperative maxillo-mandibular fixation (MMF). The aim of this study was to analyse the use of perioperative MMF and its effects on occlusal outcomes in the management of mandibular fractures. MATERIAL AND METHODS: This multicentric prospective study included adult patients with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate, partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, type of ORIF (rigid, non-rigid or mixed), thickness and number of plates, modality of intraoperative MMF (arch bars, self-tapping and self-drilling screws [STSDSs], manual, other) and duration of postoperative MMF. The primary outcome was malocclusion at 6 weeks and 3 months. Statistical analyses were performed with Fisher's exact test or chi-square test, as appropriate. RESULTS: Between 1 May 2021 and 30 April 2022, 336 patients, 264 males and 72 females (median age, 28 years) with mandibular fractures (194 single, 124 double and 18 triple fractures) were hospitalized. Intraoperative MMF was performed in all patients. Osteosynthesis was rigid in 75% of single fractures, and rigid or mixed in 85% and 100% of double and triple fractures, respectively. Excluding patients who underwent manual reduction, postoperative MMF (median duration, 3 weeks) was performed in 140 (64%) patients, without differences by type or number of fractures (p > 0.05). No significant difference was found in the incidence of malocclusion in patients with postoperative MMF (5%, 95% confidence interval [CI], 2-10%) compared to those without (4%; 95% IC, 1-11%) (p > 0.05). CONCLUSION: Postoperative MMF was performed in more than half of the patients despite adequate fracture osteosynthesis, with wide variability amongst centers. No evidence of a reduction in the incidence of postoperative malocclusion in patients treated with postoperative MMF was found.

A Multicentric Prospective Study on Maxillofacial Trauma Due to Road Traffic Accidents: The World Oral and Maxillofacial Trauma Project.

ABSTRACT: The purpose of this prospective multicenter study was to analyze the epidemiology, patterns, and management of maxillofacial fractures due to road traffic accidents (RTAs) worldwide.Between Monday September 30, 2019 and Sunday October 4, 2020,1066 patients with RTAs related fractures were admitted to 14 maxillofacial surgery departments. The following data were analyzed: age, gender, mechanism of injury, alcohol or drug abuse at the time of trauma, maxillofacial fracture site, facial injury severity scale (FISS) score, associated injuries, day and month of trauma, time of treatment, type of treatment and length of hospital stay. Data were analyzed using bivaried and multivaried statistical analysis.Eight hundred seventy patients were male, and 196 were female. The most common mechanism of injury was motorcycle accidents (48%). More than half of the patients had fractures of the middle third of the maxillofacial skeleton. In total, 59% of the study sample underwent open reduction internal fixation. The median facial injury severity scale (3 points) and the medial hospital stay (3 days) were significantly lower in patients with seatbelts and helmet (P  < 0.001).This first prospective, multicenter epidemiological study shows that motorcycle accidents are the leading cause of RTAs related fractures, mostly in young males. Particularly in Australia and Europe, the incidence of RTAs was significantly lower. Moreover, this study found that the severity of maxillofacial lesions was significantly higher in patients without safety devices, with consequent longer hospital stay demonstrating the efficacy of road safety policies in preventing maxillofacial injury.

World Oral and Maxillofacial Trauma (WORMAT) project: A multicenter prospective analysis of epidemiology and patterns of maxillofacial trauma around the world.

BACKGROUND/AIM: The World Oral Maxillofacial Trauma (WORMAT) project was performed to analyze the causes and characteristics of maxillofacial fractures managed in 14 maxillofacial surgery divisions over a 1-year period. METHODS: The following data were collected: age, sex, cause and mechanism of maxillofacial fracture, alcohol and/or drug abuse at the time of trauma, fracture site, Facial Injury Severity Scale score (FISS), associated injury, day of trauma, timing and type of treatment, and length of hospitalization. Statistical analyses were performed using SPSS software. RESULTS: Between 30 September 2019 and 4 October 2020, 2,387 patients (1,825 males and 562 females [ratio 3.2:1], 47.6% aged 20-39 years [mean age 37.2 years, median 33.0 years]) were hospitalised. The main cause of maxillofacial fracture was road traffic accidents (RTA), which were statistically associated with male adults as like as assault, sport, and work (p<0,05). Half of the fractures involved the middle third of the face, statistically associated with fall and assault (p<0.05). Trauma in multiple locations was significantly associated with longer hospital stay (p<0.05). The mean length of hospitalization was 3.9 days (95% Confidence Interval 3.7-4.2). CONCLUSIONS: This prospective, multicenter epidemiological study confirmed that young adult males were the ones most commonly affected by maxillofacial fracture. RTAs and assaults are statistically associated with the adult population, while falls are associated with females and older population.

Retrospective Investigation of Cranial Volume and Cephalic Index in Patients with Nonsyndromic Sagittal Synostosis Operated by Total Vault Remodeling.

BACKGROUND: Premature fusion of cranial sutures affects skull development and leads to head deformity. Intracranial pressure increase and brain growth restriction can occur in untreated craniosynostosis. Operative treatment aims to achieve an immediate and long-lasting correction of skull shape that is close to the average and to prevent or release possible increased intracranial pressure by increasing the intracranial volume (ICV) or normalizing the ICV if it is already below the standards. This study was designed to evaluate the effect of a total calvarial reconstruction on skull development in patients with nonsyndromic sagittal synostosis. MATERIAL AND METHODS: The study population included 19 male and 5 female patients with isolated nonsyndromic sagittal suture synostosis. During the operation, temporarily fixed prebent metal plates provided an intraoperative reference for the desired cranial expansion gain of height and shortening. Preoperative and postoperative ICVs and cephalic indices were measured on computed tomography datasets using the software program ImageJ and were compared with one another and with normative data. RESULTS: The male population presented with a preoperative mean ICV of 863.3 cm³. A postoperative mean ICV increase of 243.5 cm³ (p < 0.001) and a further ICV enlargement (p < 0.001) was measured. The mean CI changed from 71.0% preoperatively to 75.4% postoperatively (p = 0.002) and decreased insignificantly in the follow-up (p = 0.546). The female population had a preoperative mean ICV of 804.9 cm³. Postoperatively, the mean ICV increased by 211.1 cm³ (p = 0.043) and also increased in the follow-up (p = 0.043). Their mean CI values increased from 66.5% preoperatively to 72.8% (p = 0.043) postoperatively and decreased insignificantly in the follow-up (p = 0.345). CONCLUSION: This method of total vault remodeling provides reliable ICV increase and improvement in length and width of skull proportions beyond the immediate postoperative period together with an ICV increase.

A multicentric, prospective study on oral and maxillofacial trauma in the female population around the world.

BACKGROUND/AIMS: Approximately 20% of patients with maxillofacial trauma are women, but few articles have analysed this. The aim of this multicentric, prospective, epidemiological study was to analyse the characteristics of maxillofacial fractures in the female population managed in 14 maxillofacial surgery departments on five continents over a 1-year period. METHODS: The following data were collected: age (0-18, 19-64, or ≥65 years), cause and mechanism of the maxillofacial fracture, alcohol and/or drug abuse at the time of trauma, fracture site, Facial Injury Severity Scale score, associated injury, day of trauma, timing and type of treatment, and length of hospitalization. RESULTS: Between 30 September 2019 and 4 October 2020, 562 of 2387 patients hospitalized with maxillofacial trauma were females (24%; M: F ratio, 3.2:1) aged between 1 and 96 years (median age, 37 years). Most fractures occurred in patients aged 20-39 years. The main causes were falls (43% [median age, 60.5 years]), which were more common in Australian, European and American units (p < .001). They were followed by road traffic accidents (35% [median age, 29.5 years]). Assaults (15% [median age, 31.5 years]) were statistically associated with alcohol and/or drug abuse (p < .001). Of all patients, 39% underwent open reduction and internal fixation, 36% did not receive surgical treatment, and 25% underwent closed reduction. CONCLUSION: Falls were the main cause of maxillofacial injury in the female population in countries with ageing populations, while road traffic accidents were the main cause in African and some Asian centres, especially in patients ≤65 years. Assaults remain a significant cause of trauma, primarily in patients aged 19-64 years, and they are related to alcohol use.

Characteristics and age-related injury patterns of maxillofacial fractures in children and adolescents: A multicentric and prospective study.

BACKGROUND/AIMS: Paediatric maxillofacial trauma accounts for 15% of all maxillofacial trauma but remains a leading cause of mortality. The aim of this prospective, multicentric epidemiological study was to analyse the characteristics of maxillofacial fractures in paediatric patients managed in 14 maxillofacial surgery departments on five continents over a 1-year period. METHODS: The following data were collected: age (preschool [0-6 years], school age [7-12 years], and adolescent [13-18 years]), cause and mechanism of the maxillofacial fracture, alcohol and/or drug abuse at the time of trauma, fracture site, Facial Injury Severity Scale score, associated injuries, day of the maxillofacial trauma, timing and type of treatment, and length of hospitalization. Statistical analyses were performed using SPSS software. RESULTS: Between 30 September 2019 and 4 October 2020, 322 patients (male:female ratio, 2.3:1) aged 0-18 years (median age, 15 years) were hospitalized with maxillofacial trauma. The most frequent causes of the trauma were road traffic accidents (36%; median age, 15 years), followed by falls (24%; median age, 8 years) and sports (21%; median age, 14 years). Alcohol and/or drug abuse was significantly associated with males (p < .001) and older age (p < .001). Overall, 474 fractures were observed (1.47 per capita). The most affected site was the mandibular condyle in children <13 years old and the nose in adolescents. The proportion of patients who underwent open reduction and internal fixation increased with age (p < .001). CONCLUSION: The main cause of paediatric maxillofacial fractures was road traffic accidents, with the highest rates seen in African and Asian centres, and the frequency of such fractures increased with age. Falls showed an inverse association with age and were the leading cause of trauma in children 0-6 years of age. The choice of treatment varies with age, reflecting anatomical and etiological changes towards patterns more similar to those seen in adulthood.

A multicentric prospective analysis of maxillofacial trauma in the elderly population.

BACKGROUND/AIMS: The growth of the global elderly population will lead to an increase in traumatic injuries in this group, including those affecting the maxillofacial area, with a heavier load on health systems. The aim of this multicentric prospective study was to understand and evaluate the incidences, causes and patterns of oral and maxillofacial injuries in patients aged over 60 years admitted to 14 maxillofacial surgical departments around the world. METHODS: The following data were collected: gender, cause and mechanism of maxillofacial fracture, alcohol and drug abuse at the time of trauma, fracture site, Facial Injury Severity Scale score, associated injury, day of trauma, timing and type of treatment and length of hospitalization. Statistical analyses were performed using non-parametric and association tests, as well as linear regression. RESULTS: Between 30 September 2019 and 4 October 2020, 348 out of 2387 patients (14.6%), 197 men and 151 women (ratio 1.3:1; mean age 72.7 years), were hospitalized. The main causes of the maxillofacial fractures were falls (66.4%), followed by road traffic accidents (21.5%) and assaults (5.2%). Of the 472 maxillofacial fractures, 69.7% were in the middle third of the face, 28% in the lower third and 2.3% in the upper third. Patients with middle third fractures were on average 4.2 years older than patients with lower third fractures (95% CI 1.2-7.2). Statistical analysis showed that women were more involved in fall-related trauma compared with males (p < .001). It was also shown that road traffic accidents cause more fractures in the lower third (p < .001) and in the middle third-lower third complex compared with upper third (p < .001). CONCLUSIONS: Maxillofacial fractures in the elderly were more frequent in European and Australian centres and affected men slightly more than women. Falls were the leading cause of fractures, especially among women. The middle third of the face was most often affected, and conservative treatment was the most common choice for the management of such patients.

Surgical Management of Bilateral Mandibular Angle Fractures With a Third Molar in Line of Fracture: A European Multicenter Survey.

PURPOSE: The aim of this survey was to investigate the surgical management of bilateral mandibular angle fracture (BMAF) in Europe. METHODS: Data were collected from 2008 to 2018 on patients ≥ 16 years of age who underwent open reduction internal fixation (ORIF) for BMAF with a third molar in the fracture line. The study was conducted at 6 European trauma centers. The following data were recorded: sex, age, cause of the fracture, type of fracture (nondisplaced, displaced, comminuted), type of approach (intraoral, transbuccal, or extraoral), thickness of the plate (≤1.4 mm or ≥1.5 mm), number of plates, cause of plate removal, and third molar extraction status. RESULTS: 25 patients with BMAF (24 males, 1 female, 17 to 83 years old [mean: 28.2 years]) were collected. The main cause of BMAF was assault, and the main surgical approach was intraoral. The most common types of BMAF were displaced + undisplaced (11 patients), displaced + displaced (7 patients), undisplaced + undisplaced (6 patients), and comminuted + comminuted (1 patient). Osteosynthesis was performed with 2 ≤1.4 mm plates on 1 angular fracture and 1 ≤1.4 mm plate on the other fracture in 11 patients, 1 ≤1.4 mm plate on both angular fractures in 6 patients, 1 ≥1.5 mm plate on both fractures in 5 patients, and 2 ≤1.4 mm plates on both fractures in the remaining 3 patients. Out of 25 patients with BMAF, 7 third molars were extracted during ORIF. Among these patients, angular fracture fixation was performed in 3 cases with 1 ≥1.5 mm plate and in 4 patients with 2 ≤1.4 mm plates. CONCLUSIONS: This retrospective multicenter survey indicates a trend of treating with open reduction and rigid internal fixation at least 1 angular fracture of BMAF and those cases requiring extraction of the third molar in the line of fracture.