Non-Surgical Site-Related Complications in Mandibular Fracture Surgery - A Problem of Elderly Patients?

BACKGROUND: Scientific evidence of nonsurgical site-related complications in mandibular fracture patients is limited. PURPOSE: The purpose was to measure the frequency of nonsurgical site complications in patients with mandible fractures, describe the types of complications, and identify the risk factors associated with these complications. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study was conducted at the Helsinki University hospital between 2018 and 2021. Patients undergoing surgery with open reduction and internal fixation of mandibular fracture(s) were evaluated. Patients under 16 years of age were excluded. PREDICTOR VARIABLE: Primary predictor variable was age. Patient-related predictor variables were sex, long-term disease(s), smoking, and alcohol and/or drug abuse. Injury and fracture-related variables were injury mechanism, type and site of facture, combined craniofacial fracture(s), and associated injury(s). MAIN OUTCOME VARIABLE(S): The primary outcome variable was nonsurgical site-related postoperative complication. The secondary outcome variable was type of complication. COVARIATES: Not applicable. ANALYSES: The main outcome variable was cross tabulated for pairwise comparisons with predictor variables. Multivariate logistic regression was performed for statistically significant (P < .05) variables. RESULTS: The data included 314 patients (age range: 16 to 89 years; mean age: 38 years old; median age: 33 years old); most (78.3%) were men. Nonsurgical site-related postoperative complications occurred in 6.7% of patients. The most common complication type was pulmonary complication (36.0%), followed by urinary complication (20.0%) and general infection (16.0%). Nonsurgical site-related postoperative complications were most likely to occur in patients who were elderly (adjusted odds ratio [aOR] 5.55; 95% CI 1.92 to 16.21; P = .002), had combined craniofacial fractures (aOR 2.92; 95% CI 1.06 to 8.03; P = .038), and abused alcohol or drugs (aOR 4.51; 95% CI 1.70 to 11.96; P = .003). Pulmonary complications occurred more often in elderly patients, whereas urinary complications were more common in younger patients. CONCLUSIONS AND RELEVANCE: The types of nonsurgical site complications in mandibular fracture patients increase and vary according to the patient's age. Awareness of possible complications related to different age groups helps anticipate and identify these in clinical work, and to consider the overall treatment of the patient beyond the fracture.

Applicability of an active matrix metalloproteinase-8 point-of-care test in an oral and maxillofacial surgery clinic: a pilot study.

OBJECTIVES: Matrix metalloproteinases are enzymes that participate in numerous inflammatory responses and have been targeted as biomarkers in numerous pathologic states. The detection of active matrix metalloproteinase-8 (aMMP-8) using a mouthrinse point-of-care test (POCT) has emerged as a diagnostic marker for periodontitis and other systemic inflammatory states. The objective of this pilot study was to assess the applicability of aMMP-8 POCT in an oral and maxillofacial surgery clinic and to evaluate the relationship between aMMP-8 levels and different patient groups. MATERIALS AND METHODS: aMMP-8 POCT samples were collected from patients in an oral and maxillofacial surgery clinic during a one-month period. aMMP-8 levels were analyzed using a chairside lateral-flow immunotest and a digital reader. Clinically relevant patient variables were collected and descriptively evaluated. aMMP-8 levels over 20 ng/ml were considered to be elevated. RESULTS: A total of 115 patients were interviewed of which 112 agreed to the test (97.4%). Elevated aMMP-8 levels were observed in 58 (51.8%) patients. Bone loss was noted in 75 (67.0%) patients. Of these patients, aMMP-8 levels were elevated in 47 (62.7%) patients. Patients at an increased risk of infection had 35.5% higher aMMP-8 values on average compared to patients with no prior illnesses. CONCLUSION: aMMP-8 POCT provides a non-invasive and reliable method for measuring aMMP-8 levels. Future studies are warranted to assess the clinical relevance between elevated aMMP-8 levels and specific patient groups. CLINICAL RELEVANCE: The rapid availability of the test score allows an immediate impact on treatment planning.

Postoperative wound dehiscence in mandibular fractures.

OBJECTIVE: To clarify the occurrence and causes of non-infection-related surgical wound dehiscence (SWD) in intraorally treated mandibular fractures. MATERIAL AND METHODS: Patients with one or two fractures of the dentate part of the mandible treated surgically via an intraoral approach were included in this retrospective study. The primary outcome variable was SWD. Associations between patient-, fracture- and surgery-related variables and SWD were evaluated. RESULTS: Altogether 232 patients with 270 mandibular angle, body, symphysis and/or parasymphysis fractures were included in the analysis. In all, 22 SWDs were detected. These occurred in 9.5% of patients and in 8.1% of fractures. Surgery performed at night-time showed a significantly higher SWD rate than daytime surgeries (p = .012). Additionally, a significantly greater SWD rate was found among smokers (p = .041). Other studied variables remained statistically non-significant for SWD. In a multivariate analysis, night-time was the only significant independent variable with an odds ratio of 3.297 (95% CI 1.238 - 8.780, p = .017) for SWD. CONCLUSION: The approach or closure technique used and the fracture type had only a minor effect on non-infection-related SWD in patients with mandibular fractures. To avoid SWDs, mandibular fracture surgeries should be conducted during the daytime with adequate support from an experienced surgeon.

The combined anterolateral thigh-Partial iliac crest minihybrid free flap for mandibular reconstruction.

BACKGROUND AND AIMS: Tumors of the oral cavity often require extensive resections leading to significant hard and soft tissue defects. Microvascular free flaps, consisting of both hard and soft tissue, are often required in reconstructions. Hybrid flaps, composed of two different joint free flaps, offer potential alternatives for head and neck reconstruction. This report presents our results with a modified hybrid ALT/DCIA, that is, minihybrid free flap (MH-flap) composed of the anterolateral thigh (ALT) and a partial inner lamina iliac crest only (partial DCIA) for reconstruction of the mandibular region. PATIENTS AND METHODS: Eight patients underwent oral cancer reconstruction of the mandible with the MH-flap. The MH-flap was harvested sparing the outer crest and lamina of crista, and its pedicle was combined to the distal pedicle of ALT. Clinical data and postoperative complications were analyzed. RESULTS: The mean length of the osseous graft was 64 mm (range 54-78 mm). None of the patients had complications requiring surgical intervention. No donor site complications were observed. The overall survival rate was 100%. The mean length of follow-up was 16 months (range 7-30 months). CONCLUSIONS: According to our results, the ALT-partial DCIA MH-flap has postoperative outcomes comparable to those of the fibular flap. The flap is a good option with excellent bone properties for reconstruction of limited mandibular defects not suitable for fibular or scapular reconstruction.

Simple dentate area fractures of the mandible - can we prevent postoperative infections?

OBJECTIVE: To evaluate the occurrence of surgical site infections and predisposing factors for these in simple mandibular fractures. MATERIAL AND METHODS: A retrospective study of patients with fractures of the dentate part of the mandible included patients with intraorally treated simple fractures of the mandibular body, symphysis, and parasymphysis. The primary outcome variable was postoperative surgical site infection. Use of antibiotics, injury mechanism, fracture and surgery-related explanatory variables, patient-related variables and level of oral hygiene according to the modified Total Dental Index were evaluated. RESULTS: Of 254 patients with mandibular fractures, 107 were included in the final analysis. The infection group consisted of 18 patients (16.8%). Despite the high infection occurrence, significant differences were not found between antibiotic use or other studied variables and infection occurrence. Infections occurred mainly in patients without any specific explanatory factor for infection. CONCLUSION: The notably high occurrence of surgical site infections despite antibiotic use after simple mandibular fracture surgery highlights the importance of perioperative tissue handling and local oral circumstances. It is also necessary to consider whether we generally accept the high risk of infection associated with the intraorally treated simple mandibular fractures.

Mandibular fractures in aged patients - Challenges in diagnosis.

BACKGROUND/AIMS: Delayed treatment of a mandibular fracture can lead to complications. Therefore, early diagnosis is important. The aim of this study was to clarify the specific features of mandibular fractures in aged patients and the effect of age on possible missed diagnoses. MATERIAL AND METHODS: Patients aged over 60 years with a recent mandibular fracture were included in the study. The outcome variable was a missed mandibular fracture during the patient's first assessment in the primary health care facility. Predictor variables were age group, categorized as older adults (aged ≥60 and <80 years), elders (aged >80 years), patient's age as a continuous variable and age sub-group divided into decades. Additional predictor variables were the patient's memory disease and injury associated with intracranial injury. Explanatory variables were gender, injury mechanism, type of mandibular facture, combined other facial fracture, edentulous mandible/maxilla/both, surgical treatment of the mandibular fracture, and scene of injury. RESULTS: Mandibular fractures were missed in 20.0% of the 135 patients during their first healthcare assessment. Significant associations between missed fractures and age group, gender, fracture type, or injury mechanism were not found. By contrast, memory disorder (p = .02) and site of injury (p = .02) were significantly associated with missed fractures. Fractures were missed more frequently in patients who were in hospital or in a nursing home at the time of injury. CONCLUSIONS: There is an increased risk of undiagnosed mandibular fractures in the aged population. Small injury force accidents may cause fractures in old and fragile individuals. Careful examination is necessary, especially in patients with memory disorder.

Craniofacial Fractures in Equine-Related Injuries: What Should a Maxillofacial Surgeon Expect?

ABSTRACT: Patients with equine-related injuries (ERI) have high rates of hospitalization and often require surgical treatment. This study aimed to clarify the injury profiles of patients sustaining ERI-related craniofacial fractures and their relationship with other severe head and neck injuries.This retrospective study included all patients with craniofacial fractures admitted to a tertiary trauma center during 2013 to 2018. Out of 3256 patients, a total of 39 patients were included in the study (1.2%). Demographic and clinically relevant variables were reported and statistically evaluated.Males represented only 7.7% of the study population. Isolated facial fractures were over-represented in this study population at 84.6% whereas only 7.7% of patients sustained isolated cranial fractures and 7.7% of patients sustained combined craniofacial fractures, respectively. Surgical intervention for craniofacial fractures was required in 48.7% of patients. In total, 17.9% of patients sustained severe head and neck injuries. Periods of unconsciousness and/or post-traumatic amnesia were seen in 41% of patients. Helmet use could only be confirmed in 17.9% of patients.As trauma mechanisms behind ERI are often multifactorial and patients are at a high risk of sustaining associated injuries, attentive examination, and exclusion of serious life-threatening injuries through a multi-disciplinary approach is imperative for this specific patient population.

Prevalence of bacteraemia following dental extraction - efficacy of the prophylactic use of amoxicillin and clindamycin.

OBJECTIVES: To evaluate the efficacy of single-dose antibiotic prophylaxis (AP) in the prevention of bacteraemia following tooth extractions at our clinic. MATERIAL AND METHODS: Fifty patients undergoing tooth extractions were enrolled. The need of AP was determined according to the health status and possible allergies of the patients. Blood culture samples were collected at baseline, 5 min after the first tooth extraction and 20 min after the last extraction. RESULTS: The majority (76%) received prophylactic oral amoxicillin or intravenous ampicillin (AMX/AMP) (2 g), 12% received clindamycin (CLI) (600 mg) and 12% received no prophylaxis (NO AP). All baseline blood cultures were reported negative. The prevalence of bacteraemia was significantly higher in the CLI and NO AP groups compared to the AMX/AMP group 5 min after the first tooth extraction (p < .0001 and p = .015, respectively). Twenty minutes after the last extraction positive blood cultures were reported only for CLI (p = .0015) and NO AP groups. There was no significant difference in the prevalence of positive blood cultures between CLI and NO AP groups. CONCLUSIONS: Appropriately administered AMX/AMP proved its efficacy in reducing both the prevalence and duration of bacteraemia following tooth extractions whereas CLI was not effective in preventing bacteraemia following tooth extractions.

Periodontitis in tonsil cancer patients-A comparative study in accordance with tumour p16 status.

OBJECTIVES: We assessed the periodontal situation radiologically according to tumour p16 status. MATERIALS AND METHODS: Patients with a diagnosis of tonsillar cancer and availability of a digital panoramic radiograph (DPR) during a 5-year period were included in this retrospective study. The predictor variables were periodontal stability, marginal bone loss, marginal bone loss without periodontal stability and total number of teeth. Periodontal status was compared with p16 status, age, gender, smoking and alcohol use. RESULTS: Among 115 patients included in the analyses (p16-negative, n = 24; p16-positive, n = 91), smoking (p < .0001), heavy alcohol use (p < .0001) and total number of teeth (p = .0001) were significantly associated with p16 status. Current smoking (OR = 7.3) and heavy alcohol use (OR = 10.1) increased the risk of p16-negative cancer. CONCLUSIONS: Patients with p16-negative tonsillar carcinoma had less teeth than patients with p16-positive tumours. Other periodontal findings were common in both groups without statistical significance. Heavy alcohol use and smoking were the most important risk factors for p16-negative tonsillar carcinoma.

Expression of Toll-like receptors in oral squamous cell carcinoma.

Almost 380,000 new cases of oral cancer were reported worldwide in 2020. Oral squamous cell carcinoma (OSCC) accounts for 90% of all types of oral cancers. Emerging studies have shown association of Toll-like receptors (TLRs) in carcinogenesis. The present study aimed to investigate the expression levels and tissue localization of TRL1 to TRL10 and NF-κB between OSCC and healthy oral mucosa, as well as effect of Candida colonization in TRL expression in OSCC. Full thickness biopsies and microbial samples from 30 newly diagnosed primary OSCC patients and 26 health controls were collected. The expression of TLR1 to TLR10 and NF-κB was analyzed by immunohistochemistry. Microbial samples were collected from oral mucosa to detect Candida. OSCC epithelium showed lower staining intensity of TRL1, TRL2 TRL5, and TRL8 as compared to healthy controls. Similarly, staining intensity of TRL3, TRL4, TRL7, and TRL8 were significantly decreased in basement membrane (BM) zone. Likewise, OSCC endothelium showed lower staining intensity of TLR4, TLR7 and TLR8. Expression of NF-κB was significantly stronger in normal healthy tissue compared to OSCC sample. Positive correlation was found between the expression of NF-κB, TRL9 and TRL10 in basal layer of the infiltrative zone OSCC samples (P = 0.04 and P = 0.002, respectively). Significant increase in TRL4 was seen in BM zone of sample colonized with Candida (P = 0.01). According to the limited number of samples, our data indicates downregulation of TLRs and NF-κB in OSCC, and upregulation of TLR4 expression with presence of Candida.

Dental injuries in paediatric mandibular fracture patients.

PURPOSE: Dental injuries (DIs) are associated with facial fractures, particularly mandibular fractures. As paediatric mandibular fractures have special features, we sought to clarify the occurrence and types of DIs among this patient group. We assessed how age, injury type, and fracture location affects the occurrence of DIs and thereby defined which patients are most susceptible. METHODS: This retrospective study included patients < 18 years with a recent mandibular fracture. Predictor variables were gender, age group, mechanism of injury, type of mandibular fracture, and other associated facial fracture(s). Types and locations of DIs and tooth loss due to injury were also reported. RESULTS: DIs were detected in 34.7% (n = 41) out of 118 patients. Patients with tooth injury had on average 3.5 injured teeth. A total of 16.2% of injured teeth were lost, typically at the time of the injury. Loss of at least one tooth was seen in approximately 10% of patients. Avulsion was the most common cause of tooth loss (52.2%). Non-complicated crown fracture (50.7%) was the most common DI type. Statistically significant associations between studied variables and DIs were not detected. CONCLUSION: DIs are common and often multiple in paediatric mandibular fracture patients regardless of background factors. DIs often lead to tooth loss. Prompt replantation of an avulsed tooth, early detection of DIs, and prevention of tooth loss whenever possible are important to avoid permanent tooth defects.

Implant malposition and revision surgery in primary orbital fracture reconstructions.

The aim of the study was to assess factors leading to revision surgery and implant position of primary orbital fracture reconstructions. A retrospective cohort included patients who underwent orbital floor and/or medial wall fracture reconstruction for recent trauma. Demographics, fracture type, surgery and implant-related variables, and postoperative implant position were analyzed. The overall revision surgery rate was 6.5% (15 of 232 surgeries). The rate was highest in combined midfacial fractures with rim involvement (14.0%), lower in zygomatico-orbital fractures (8.7%), and lowest in isolated blowout fractures (3.8%). Fracture type, orbital rim fixation and implant malposition predicted revision. The best positioning was achieved with patient-specific milled titanium implants (mtPSI) and resorbable materials, whereas the poorest with preformed three-dimensional titanium plates. Combined midfacial fractures with rim involvement in particular have a high risk for orbital revision surgery. Within the limitations of the present study, mtPSIs should be preferred in the reconstruction of primary orbital fractures if possible.

Expression of p53 is associated with microbial acetaldehyde production in oralsquamous cell carcinoma.

OBJECTIVES: The objective of this study was to investigate the association between p53 expression and microbial acetaldehyde production in patients with oral squamous cell carcinoma (OSCC). STUDY DESIGN: Oral mucosal biopsies from 22 patients with OSCC and 24 healthy controls (HCs) were collected. p53 expression was analyzed by immunohistochemistry. Microbial samples were collected from the mucosa and microbial acetaldehyde production from ethanol was measured by gas chromatography. RESULTS: The majority of all OSCC (77%) and HC samples (67%) produced mutagenic levels of acetaldehyde (>100 µM). A significant positive correlation between microbial acetaldehyde production and p53 expression levels in OSCC samples was seen in the intermediate and superficial layers of the epithelium of the infiltrative zone (P = .0005 and P = .0004, respectively) and in the superficial layer of the healthy appearing mucosa next to the tumor (P = .0391). There was no significant correlation between acetaldehyde levels and p53 expression in HC samples. CONCLUSIONS: Our results show an association between microbial acetaldehyde production and immunostaining of p53 in OSCC samples.

Patient injury-related alcohol use-underestimated in patients with facial fractures?

OBJECTIVE: The aim of this study was to highlight the current underestimation of the role of alcohol in facial fracture etiology and patients' daily life. STUDY DESIGN: A prospective cross-sectional study was conducted. Alcohol consumption habits were evaluated, and data were collected through a constructed questionnaire and interview. Case-related data collection was performed, with the primary predictor variables being mechanism of injury; fracture type; and associated injury (any). Outcome variables were alcohol involved in injury (yes/no) and heavy alcohol use (yes/no). The explanatory variables were gender and age. Descriptive and bivariate statistics were computed, and the P value was set at .05. RESULTS: In total, 166 patients were included in the study. Of these, 55% of patients reported being under the influence of alcohol when they sustained the injury. Alcohol was involved most often among male patients (P = .0006) and in the younger age groups (P < .0001). Of the study patients, 17% reported heavy alcohol use. The majority of the interpersonal violence events had taken place under the influence of alcohol (84%; P < .0001). CONCLUSIONS: The role of alcohol in facial fracture etiology is significant. A brief intervention for alcohol abuse should be included routinely in patient care to identify and, if necessary, address this problem.

TLR1-10, NF-κB and p53 expression is increased in oral lichenoid disease.

Toll-like receptors (TLRs) and nuclear factor-κB (NF-κB) in keratinocytes play an important role in dermatological autoimmune diseases. Tumour suppressor protein p53 regulates TLR expression. The aim of this study was to compare the expression of TLR1-TLR10, p53 and NF-κB in patients with oral lichenoid disease (OLD) with healthy mucosa. Oral mucosal biopsies from 24 patients with OLD and 26 healthy controls (HC) were analysed for the expression of TLR1-TLR10, NF-κB and p53 by immunohistochemistry. The expression of all TLRs was increased in OLD epithelia compared to HC samples and the difference was significant in TLR1, TLR3, TLR4, TLR5, TLR6 and TLR7. In the basement membrane zone, the immunoreactivity of TLR5 was significantly more intense in OLD compared to HC. In the intermediate layer, the immunoreactivity of NF-κB was significantly stronger in OLD, whereas the staining for p53 was more intense in all layers of OLD compared to HC samples. In OLD, a positive correlation between TLR2 and NF-κB in the basal layer and between TLR5, p53 and NF-κB in the intermediate layers was discovered. The expression of TLRs, p53 and NF-κB is increased in OLD, which may play a role in the pathogenesis of this chronic immune-mediated mucosal disease.

Intracellular localization of Treponema denticola chymotrypsin-like proteinase in chronic periodontitis.

Treponema denticola is an important periodontal pathogen capable of tissue invasion. Its chymotrypsin-like proteinase (CTLP) can degrade a number of basement membrane components in vitro, thus suggesting a contribution to tissue invasion by the spirochete. The aim of this study was to analyze the localization of CTLP in chronic periodontitis tissues ex vivo. A polyclonal antibody specific to T. denticola cell-bound CTLP was used to detect the spirochetes in the gingival tissues of patients with moderate to severe chronic periodontitis (n=25) by immunohistochemistry and periodic acid-Schiff staining (PAS). The presence of T. denticola in the periodontal tissue samples was analyzed by PCR. Periodontal tissue samples of 12 of the 25 patients were found to be positive for T. denticola by PCR. Moreover, CTLP could be detected in the periodontal tissues of all these patients by immunohistochemistry. In the epithelium, the CTLP was mostly intracellular. Typically, the positive staining could be seen throughout the whole depth of the epithelium. When detected extracellularly, CTLP was localized mainly as granular deposits. The connective tissue stained diffusely positive in four cases. The positive staining co-localized with the PAS stain in nine cases. T. denticola and its CTLP could be detected in diseased human periodontium both intra- and extracellularly. The granular staining pattern was suggestive of the presence of T. denticola bacteria, whereas the more diffused staining pattern was indicative of the recent presence of the bacterium and shedding of the cell-bound proteinase.

Acetaldehyde production and microbial colonization in oral squamous cell carcinoma and oral lichenoid disease.

OBJECTIVE: The main aim of this prospective study was to explore the ability of the oral microbiome to produce acetaldehyde in ethanol incubation. STUDY DESIGN: A total of 90 patients [30 oral squamous cell carcinoma (OSCC); 30 oral lichenoid disease (OLD); 30 healthy controls (CO)] were enrolled in the study. Microbial samples were taken from the mucosa using a filter paper method. The density of microbial colonization was calculated and the spectrum analyzed. Microbial acetaldehyde production was measured by gas chromatography. RESULTS: The majority (68%) of cultures produced carcinogenic levels of acetaldehyde (>100 µM) when incubated with ethanol (22 mM). The mean acetaldehyde production by microbes cultured from smoker samples was significantly higher (213 µM) than from non-smoker samples (141 µM) (P=.0326). CONCLUSIONS: The oral microbiota from OSCC, OLD patients and healthy individuals are able to produce carcinogenic levels of acetaldehyde. The present provisional study suggests smoking may increase the production of acetaldehyde.