Maxillofacial trauma in the emergency department: a review.

OBJECTIVES: In 1978 the Advanced Trauma Life Support guidelines were first implemented and are viewed by many as the gold standard of care in the emergency setting. It may not be immediately obvious where assessment and management of maxillofacial injuries fits within these trauma guidelines. This article aims to provide a concise, contemporary guide for the treatment of maxillofacial trauma in the emergency setting. METHODS: An electronic database search was conducted in PubMed and Science Direct on articles from 1970 to the present day. The key search terms were Maxillofacial, Trauma, ATLS, Advanced Trauma Life Support, EMST, Early Management of Severe Trauma, Airway, Eye, Ophthalmic and Management. The findings were compiled into a review article. The article was then reviewed by experts in the fields of Maxillofacial Surgery and Ophthalmology to ensure content and contextual accuracy. RESULTS: Physicians are becoming increasingly exposed to major maxillofacial injuries. Resuscitative measures can be complex and require prompt decisions especially in gaining a secure airway. A proposed treatment algorithm for maxillofacial trauma patients has been devised by the authors. CONCLUSIONS: It is imperative that sight preserving assessment and interventions are not forgotten in the emergency management of maxillofacial trauma. We propose an algorithm for the management of maxillofacial trauma, and recommend the use of CT as a powerful adjunct to clinical examination in patients with maxillofacial trauma.

Magnetic resonance imaging for three-dimensional printing of the bony orbit: is clinical use imminent?

The aim of this study was to examine the accuracy of three dimensionally (3D) printed models of the bony orbit derived from magnetic resonance imaging (MRI) for the purpose of preoperative plate bending in the setting of orbital blowout fracture. Retrospective computed tomography (CT) and MRI data from patients with suspected orbital fractures were used. Virtual models were manually generated and analysed for spatial accuracy of the fracture margins. 3D-printed models were produced and orbital fan plates bent by a single operator. The plates were then digitized and analysed for spatial discrepancy using reverse engineering software. Seven orbital blowout fractures were evident in six orbits. Analysis of the virtual models revealed high congruence between blowout fracture margins on CT and MRI (n=7, average deviation 0.85mm). Three zygomaticomaxillary complex fractures were seen, for which MRI did not demonstrate the same accuracy. For plates bent to the 3D-printed models of blowout fractures (n=6), no significant difference was found between those bent to CT versus those bent to MRI when compared for average surface and average border deviation (Wilcoxon signed rank test). Orbital blowout fractures can be defined on MRI with clinically acceptable accuracy. 3D printing of orbital biomodels from MRI for bending reconstructive plates is an acceptable and accurate technique.

Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial.

To evaluate the effect of postoperative irrigation with chlorhexidine on inflammatory complications after the extraction of lower third molars under local anaesthesia, we recruited 100 patients to participate in a controlled, single-blind, randomised clinical trial. They were assigned to one of two groups: the intervention group (postoperative irrigation of the surgical site with chlorhexidine for seven days) or the control group (postoperative chlorhexidine mouth rinse for seven days). The primary outcome variables were pain, swelling, trismus, infection, and alveolar osteitis. The secondary outcome variables were wound dehiscence and food impaction. A total of 95 participants completed the study (47 in the irrigation group and 48 in the rinse group). In the irrigation group, alveolar osteitis and facial swelling had reduced significantly at seven days postoperatively (both p<0.01). Pain scores had also reduced significantly at seven days (p<0.01), but not at 48hours, and patients had lower levels of food impaction (p<0.01) and less severe symptoms (p=0.02). Routine irrigation with chlorhexidine after the extraction of third molars helps to reduce pain and lowers the incidence of alveolar osteitis.

Postoperative interventions to reduce inflammatory complications after third molar surgery: review of the current evidence.

Inflammatory complications such as pain, swelling, trismus, infection and alveolar osteitis have an adverse affect on the quality of life of patients after third molar removal. This review presents the current evidence on postoperative strategies to reduce these complications. A literature search was performed to identify articles published in English between 2000 to 2016 using the following keywords: third molar(s), wisdom tooth/teeth, pain, swelling, trismus, infection, alveolar osteitis and dry socket. In total, 221 papers were reviewed. Methods published included analgesics, antibiotics, corticosteroids, mouthwashes, topical gels, cryotherapy and ozone therapy. This review highlights the variability in evidence available and summarizes the findings from best-quality evidence. In conclusion, paracetamol and ibuprofen are efficacious in managing postoperative pain. Corticosteroids and antibiotics should only be used in selected cases. Chlorhexidine reduces alveolar osteitis. The benefits of cryotherapy, postoperative irrigation and ozone gel are yet to be established.

Consent for third molar tooth extractions in Australia and New Zealand: a review of current practice.

BACKGROUND: Informed consent is the legal requirement to educate a patient about a proposed medical treatment or procedure so that he or she can make informed decisions. The purpose of the study was to examine the current practice for obtaining informed consent for third molar tooth extractions (wisdom teeth) by oral and maxillofacial surgeons in Australia and New Zealand. METHODS: An online survey was sent to 180 consultant oral and maxillofacial surgeons in Australia and New Zealand. Surgeons were asked to answer (yes/no) whether they routinely warned of a specific risk of third molar tooth extraction in their written consent. RESULTS: Seventy-one replies were received (39%). The only risks that surgeons agreed should be routinely included in written consent were a general warning of infection (not alveolar osteitis), inferior alveolar nerve damage (temporary and permanent) and lingual nerve damage (temporary and permanent). CONCLUSIONS: There is significant variability among Australian and New Zealand oral and maxillofacial surgeons regarding risk disclosure for third molar tooth extractions. We aim to improve consistency in consent for third molar extractions by developing an evidence-based consent form.

The Australian litigation landscape - oral and maxillofacial surgery and general dentistry (oral surgery procedures): an analysis of litigation cases.

BACKGROUND: There are persistent concerns about litigation in the dental and medical professions. These concerns arise in a setting where general dentists are more frequently undertaking a wider range of oral surgery procedures, potentially increasing legal risk. METHODS: Judicial cases dealing with medical negligence in the fields of general dentistry (oral surgery procedure) and oral and maxillofacial surgery were located using the three main legal databases. Relevant cases were analysed to determine the procedures involved, the patients' claims of injury, findings of negligence and damages awarded. A thematic analysis of the cases was undertaken to determine trends. RESULTS: Fifteen cases over a 20-year period were located across almost all Australian jurisdictions (eight cases involved general dentists; seven cases involved oral and maxillofacial surgeons). Eleven of the 15 cases involved determinations of whether or not the practitioner had failed in their duty of care; negligence was found in six cases. Eleven of the 15 cases related to molar extractions (eight specifically to third molar). CONCLUSIONS: Dental and medical practitioners wanting to manage legal risk should have regard to circumstances arising in judicial cases. Adequate warning of risks is critical, as is offering referral in appropriate cases. Preoperative radiographs, good medical records and processes to ensure appropriate follow-up are also important.

Panoramic radiographic survey of hypodontia in Australian Defence Force recruits.

Comprehensive dental examinations and panoramic radiographs were used to determine the prevalence of hypodontia in 662 Australian Defence Force recruits. Of the sampled population, 6.3 per cent exhibited some degree of hypodontia (third molar agenesis excluded). Previous studies produced similar results. Third molar agenesis occurred in 22.7 per cent of the sample which again is in agreement with other studies. There was no statistical difference between the sexes in third molar agenesis; however, there was a significant difference with upper second premolars. Females exhibited an extremely low incidence of absence of maxillary lateral incisors.

Crohn's disease with oral presenting signs masquerading as chronic osteomyelitis.

BACKGROUND: A case of Crohn's disease (CD) was diagnosed following recognition of oral and systemic signs and symptoms in a 19-year-old male patient. METHODS: Clinical investigation utilized included blood tests (full blood count, electrolytes, urea, creatinine, liver function tests), computed tomogrphy scans, magnetic resonance imaging scans, oral biopsies, colonoscopy and biopsies of the terminal ileum and colon. RESULTS: A diagnosis of CD was made which then allowed appropriate medical treatment to be initiated. CONCLUSION: The importance of a thorough medical history and full physical examination with appropriate investigations as dictated by clinical findings is demonstrated.

Impact of malocclusion and orthognathic reconstruction surgery on resonance and articulatory function: an examination of variability in five cases.

Articulatory patterns and nasal resonance were assessed before and 6 months after orthognathic reconstruction surgery in five patients with dentofacial deformities. Perceptual and physiological assessments showed disorders of nasality and articulatory function preoperatively, two patients being hyponasal, and one hypernasal. Four patients had mild articulatory deficits, and four had reduced maximal lip or tongue pressures. Operation resulted in different patterns of change. Nasality deteriorated in three patients and articulatory precision and intelligibility improved in only one patient and showed no change in the other four. Operation improved interlabial pressures in three patients, while its impact on tongue pressures varied, being improved in one case, deteriorating in one, and remaining unchanged in the other three. The variability in the results highlights the need for routine assessment of speech and resonance before and after orthognathic reconstruction.