Impact of Osteoporosis on Autogenous Bone Graft Resorption.

BACKGROUND: Osteoporosis is a common disorder that is characterized by decreased bone density and increased bone resorption. This bone resorption may affect the grafted bone during the maxillofacial reconstruction. PURPOSE: This study aimed to measure the association between osteoporosis and resorption of anterior iliac crest bone grafts used to reconstruct the atrophic anterior maxillae. STUDY DESIGN, SETTING, SAMPLE: This prospective cohort study included female patients requiring bone augmentation of the anterior maxilla. Patients with a ridge width of <4 mm and ridge height of >7 mm were enrolled in the study. Exclusion criteria were chronic use of corticosteroids or intravenous bisphosphonates, history of maxillofacial radiation therapy, current smoking, and underlying conditions contributing to bone metabolism (eg, hyperparathyroidism, chronic renal failure, and hypophosphatemia). PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: Osteoporosis status was a predictor variable. Patients were allocated to the osteoporosis or control group based on T-scores obtained by dual-energy x-ray absorptiometry. Mean T-scores ≤ -2.5 were assigned to the osteoporosis group. MAIN OUTCOME VARIABLE(S): The outcome variable was graft resorption, defined as the difference in ridge width between measurements made immediately (T1) and 6 months postoperatively (T2) using cone-beam computed tomography. COVARIATES: Patient age, preoperative (T0) bone width, and the amount of bone augmentation, defined as the differences in ridge width between measurements made preoperatively (T0) and immediately after grafting (T1), were covariates of this study. ANALYSES: Descriptive, analytic, and general linear models were computed. Statistical significance was set a P < .05. RESULTS: Thirty-two patients were included in the study (15 in the osteoporosis group and 17 in the control group). The amount of graft resorption at 6 months after grafting was 2.57 ± 0.59 mm in the osteoporosis group and 0.97 ± 0.59 mm in the control group (P < .001). A significant correlation was found between the mean T-score and graft resorption 6 months after grafting (P < .001). CONCLUSION AND RELEVANCE: A significant correlation was observed between osteoporosis and graft resorption in the anterior maxilla after 6 months.

Is Insurance Payer Associated With Hospital Admission of Emergency Department Patients With Mandible Fractures?

BACKGROUND: There is a lack of consensus on the optimal triage pathway for emergency department (ED) patients with mandibular fractures. It remains unclear if patient insurance payers predict hospital admission given potentially competing logistical and health system incentives. PURPOSE: To generate nationally representative estimates of the frequency of hospital admission and its association with primary insurance payers for ED patients with mandible fractures. METHODS: This retrospective cohort study used the 2018 Nationwide Emergency Department Sample, the largest all-payer database in the United States, to identify patients with mandible fractures. The database includes a stratified sample with discharge weights to generate nationally representative estimates. Patients with other facial fractures and/or concomitant injuries that independently warranted admission were excluded. PREDICTOR: The primary predictor variable was primary payer (public, private, self-pay, and other/no charge). OUTCOME VARIABLE: The primary outcome variable was hospital admission (yes/no). COVARIATES: Covariates included patient-, medical/injury-, and hospital-related variables. ANALYSES: Descriptive statistics, along with bivariate and multivariate logistic regression with Bonferroni correction, were used to produce national estimates and identify predictors of admission. P < .01 was considered significant. RESULTS: The cohort included 27,238 weighted encounters involving isolated mandible fractures, of which 5,345(20%) were admitted. The payers for admitted patients were 46% public, 25% private, 22% self-pay, and 7% no charge/other. In bivariate analyses, public insurance was associated with a higher likelihood of admission than private insurance (RR 1.24, 95% CI 1.06 to 1.45), though there was no association in the multivariate model (OR 1.03, 95% CI 0.83 to 1.28). In multivariate analysis, higher Charlson Comorbidity Index (OR 1.32, 95% CI 1.18 to 1.48), alcohol-related disorder (OR 3.47, 95% CI 2.74 to 4.39), substance-related disorder (OR 1.43, 95% CI 1.20 to 1.71), and more mandible fractures (OR 3.08, 95% CI 2.65 to 3.59) were associated with admission. Compared to body fractures, subcondylar (OR 3.83, 95% CI 2.39 to 6.14), angle (OR 3.53, 95% CI 2.84 to 6.09), and symphysis (OR 4.14, 95% CI 2.84 to 6.09) fractures had higher odds of admission. Finally, level I (OR 4.11, 95% CI 2.41 to 6.98) and level II (OR 3.16, 95% CI 1.85 to 5.39) trauma centers had higher odds of admission. CONCLUSIONS: In 2018, 20% of ED patients with isolated mandible fractures were admitted. Several patient and hospital characteristics were predictors of admission. Insurance status was not associated with admission.

Is Cleft Lip or Palate a Risk Factor for Perioperative Complications in Orthognathic Surgery?

PURPOSE: Perioperative outcomes following cleft orthognathic surgery are not well established. The purpose of this study was to compare the incidence of orthognathic specific complications (OSCs) in patients with and without cleft lip and/or palate. METHODS: The American College of Surgeons National Surgical Quality Improvement Program adult and pediatric databases were used to enroll patients undergoing orthognathic surgery. The primary predictor variable was a prior diagnosis of cleft lip and/or palate: cleft versus noncleft. The primary outcome variable was OSCs (yes/no) within 30 days of the index operation. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between cleft status and OSCs. RESULTS: The study sample was composed of 1,149 subjects: 98 in the cleft group and 1,051 in the noncleft group. The incidence of OSCs was 6.1 and 4.7% for the cleft and noncleft groups, respectively (P = .461). After adjusting for age, cleft status, bone grafting, segmentation of the maxilla, and history of bleeding disorder, classification as American Society of Anesthesiologists (ASA) III (P = .002, odds ratio [OR] = 3.92, 95% confidence interval [CI] 1.63-9.40), ASA IV (P = .039, OR = 9.47, 95% CI 1.12-80.4), and isolated mandibular osteotomies (P = .006, OR = 3.23, 95% CI 1.40-7.48) were independent predictors of OSCs. Length of stay was 1.66 ± 1.14 days compared to 1.37 ± 3.74 days for the cleft and noncleft groups, respectively (P = .443). CONCLUSIONS: There was no significant difference in the incidence of perioperative OSCs and length of hospital stay between cleft and noncleft patients. Cleft status was not an independent predictor of OSCs; instead, greater ASA classification and isolated mandibular osteotomies were the only predisposing factors. Patients with clefts undergoing orthognathic surgery do not have an increased risk of short-term OSCs within the limitations of this study.

Does the Modified Frailty Index (mFI-5) Predict Adverse Outcomes in Maxillofacial Fracture Repair?

PURPOSE: Frailty has been recognized as a predictor of postoperative adverse outcomes in many surgical subspecialties. The purpose of this study was to evaluate the relationship between frailty and complications in patients undergoing operative repair of facial fractures. METHODS: The authors utilized the 2011 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases to identify patients with facial fractures undergoing operative repair. The primary predictor variable was frailty as measured by the 5-Factor Modified Frailty Index (mFI-5). The primary outcome variable was the postoperative complication rate. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between frailty and complications. RESULTS: During the study period, 4,290 subjects underwent operative repair of a facial fracture. Of these subjects, 4,086 (83.0%) were classified as nonfrail, 626 (12.7%) as moderately frail, and 208 (4.20%) as severely frail. A total of 237 subjects experienced a complication (4.82%), and the incidence of complications increased in a stepwise manner with increasing frailty (P ≤ .001). In multivariate regression, age (P = .050, 95% CI = 1.00 to 1.02), Native Hawaiian/Pacific Islander race (P = .018, 95% CI = 1.23 to 8.63), classification as moderately frail (P = .010, 95% CI = 1.15 to 2.66), classification as severely frail (P = .032, 95% CI = 1.06 to 3.70), mandibular fractures (P = .004, 95% CI = 1.24 to 2.98), and wound classification as contaminated (P ≤ .001, 95% CI = 1.53 to 4.57) or dirty/infected (P = .020, 95% CI = 1.16 to 5.55) were independent predictors of complications. Severely frail subjects also had greater length of hospital admission (P ≤ .001) and higher 30-day readmission rates (P ≤ .001). CONCLUSIONS: Frailty is an independent predictor of complications following facial fracture repair and is associated with greater length of hospital admission and 30-day readmission rates.

Is Intensive Care Unit Monitoring Necessary After Maxillomandibular Advancement for Management of Obstructive Sleep Apnea?

PURPOSE: Maxillomandibular advancement (MMA) is an accepted treatment modality for obstructive sleep apnea. The purpose of this study was to evaluate the incidence of complications requiring an intensive care unit (ICU) level of care and the necessity of routine overnight ICU airway monitoring after MMA. PATIENTS AND METHODS: This was a retrospective cohort study of patients undergoing MMA at Massachusetts General Hospital from 2003 to 2020. The primary predictor variable was postoperative admission to the ICU versus post anesthesia care unit (PACU) or ward. The primary outcome variable was grade IV or V complications as scored using the Clavien-Dindo classification system. The secondary outcome variables included postoperative SpO2 nadir and length of hospital stay. Descriptive and bivariate statistics were computed to measure the association between complications and predictor variables. RESULTS: The study sample consisted of 104 patients (74.0% male, mean age 37.6 ± 12.1 years), 61 of whom were admitted to the ICU (58.7%). During the initial 24 hours of airway monitoring, the mean SpO2 nadir was 93.7 ± 2.59% for patients admitted to the ICU compared with 94.0 ± 6.56% for patients admitted to the PACU or ward (P = .862). Patients experienced 2 grade IV complications (1.92%) and no grade V complications, with no statistical association between complications and postoperative admission location (P = 1.000). Age (P = .002) and operative time (P = .046) were the only variables statistically associated with grade IV or V complications. There was no difference in length of hospital stay between patients admitted to the ICU (2.64 ± 1.37 days) versus PACU or ward (2.58 ± 1.62 days). CONCLUSIONS: The incidence of complications requiring ICU-level care after MMA for obstructive sleep apnea is low. Additional studies are warranted to guide development of feasible, cost-effective perioperative protocols for patients undergoing MMA.

Interfacility Emergency Department Transfer for Mandibular Fractures in the United States.

PURPOSE: Interfacility hospital transfer for isolated mandibular fractures is common but rarely clinically necessary. The purpose of this study was to generate nationally representative estimates regarding the incidence, risk factors, and cost of transfer for isolated mandibular fractures. METHODS: This was a retrospective cohort study using the Nationwide Emergency Department Sample 2018 to identify patients with isolated mandibular fractures. The primary predictor variable was hospital trauma center designation (Level I, Level II, Level III, and nontrauma center). The primary outcome variable was hospital transfer. Total emergency department (ED) charges were also assessed. Covariates were demographic, medical, injury-related, and hospital characteristics. Descriptive, bivariate, and multiple logistic regression statistics were used to evaluate the incidence and predictors of interfacility transfer. RESULTS: A total of 28,357 encounters with mandibular fracture as the primary diagnosis were included. Within this cohort there were 2,893 hospital transfers (10.2%). In unadjusted analysis, evaluation at a nontrauma center, level III trauma center, metropolitan nonteaching hospital, nonmetropolitan nonteaching hospital, micropolitan region, and history of cerebrovascular event was associated with hospital transfer (P ≤ .001). In the adjusted model, independent predictors (risk factors) for hospital transfer were evaluation at a nontrauma center (P ≤ .001, odds ratio [OR] = 12.8, 95% confidence interval [CI] = 6.43 to 25.4), level III trauma center (P ≤ .001, OR = 10.7, 95% CI = 5.25 to 21.7), nonmetropolitan nonteaching hospital (P ≤ .001, OR = 2.45, 95% CI = 1.73 to 3.46), metropolitan nonteaching hospital (P ≤ .001, OR = 1.57, 95% CI = 1.20 to 2.06), cervical spine injury (P = .002, OR = 3.53, 95% CI = 1.61 to 7.75), fractures of the mandibular body (P = .007, OR = 1.33, 95% CI = 1.08 to 1.64), and unspecified mandibular fractures (P = .006, OR = 1.49, 95% CI = 1.12 to 1.99). The average ED charge per encounter was $7,482 ± 565 for a total nationwide charge of $212,172,264. Transferred subjects had total ED charges of $25,632,974, not including additional charges incurred at the recipient hospital. CONCLUSION: Isolated mandibular fractures are common injuries that are frequently transferred and cost the healthcare system millions of dollars annually. Hospital characteristics rather than medical or injury-related variables were the strongest predictors of transfer, suggesting that transfers are primarily driven by need to access maxillofacial surgical services. Programs evaluating necessity of transfer and facilitating specialist evaluation in the outpatient setting may reduce healthcare expenditures for this injury.

Mandibular Fracture Repair in Older Adults: Is Age Associated With Adverse Outcomes?

PURPOSE: The purpose of this study was to measure the association between age and adverse outcomes in patients undergoing open reduction internal fixation (ORIF) of mandibular fractures. METHODS: This was a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program databases (2011 to 2019) to identify patients with mandibular fractures treated with ORIF. The primary predictor variable was age (<45 years, 45 to 54 years, 55 to 64 years, 65 to 74 years, and ≥75 years). The primary outcome variable was surgical complications. Secondary outcome variables included any complication, extended length of stay (LOS ≥95th percentile), and adverse discharge destination. Covariates included demographic, medical, and perioperative covariates. Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the association between age and adverse outcomes. RESULTS: During the study period, 2,843 patients underwent ORIF of a mandibular fracture, and 2,168 subjects were included. There were 1,673 subjects aged <45 years (77.2%), 240 subjects aged 45 to 54 years (11.1%), 155 subjects aged 55 to 64 years (7.10%), 53 subjects aged 65 to 74 years (2.40%), and 47 subjects aged ≥75 years (2.20%). A total of 148 subjects (6.83%) experienced a surgical complication; the incidence of surgical complications increased in a step-wise fashion with each decade of life (P ≤ .001). In bivariate analysis, subjects aged 65 to 74 years were more likely to experience extended LOS (P = .004), whereas subjects aged ≥75 years were more likely to have an extended LOS (P ≤ .001) and an adverse discharge destination (P ≤ .001). In multivariate analysis, age 65 to 74 years was an independent predictor of any complication (P = .032, 95% confidence interval [CI] = 1.08 to 5.37), extended LOS (P = .001, 95% CI = 1.72 to 8.79), and adverse discharge destination (P = .050, 95% CI = 1.00 to 14.4), whereas age ≥75 years was an independent predictor of surgical complications (P = .043, 95% CI = 1.03 to 6.68), any complication (P = .018, 95% CI = 1.20 to 6.75), extended LOS (P = .001, 95% CI = 2.35 to 12.3), and an adverse discharge destination (P ≤ .001, 95% CI = 3.01 to 33.2). CONCLUSIONS: The elderly are at increased risk of adverse outcomes with step-wise increases in the odds of select outcomes with increasing age.

Orthognathic Surgery in Older Patients: Is Age Associated With Perioperative Complications?

PURPOSE: The incidence of older patients undergoing orthognathic surgery is increasing. The purpose of this study is to evaluate the association between age and perioperative adverse outcomes in patients undergoing orthognathic surgery. METHODS: This is a retrospective cohort study of patients undergoing orthognathic surgery in the 2011 to 2019 American College of Surgeons National Surgical Quality Improvement Program databases. The primary predictor variable was age group (≥40 or <40 years). The primary outcome variable was adverse outcomes occurring within 30 days of the index operation. Descriptive, bivariate, and Firth logistic regression statistics were utilized to evaluate association between age and adverse outcomes. RESULTS: During the study period, 1,226 patients underwent an orthognathic procedure and 835 subjects were included. Of these subjects, 145 were 40 years or older (17.4%) and 690 were less than 40 years (82.6%). Subjects 40 years or older were more likely to be American Society of Anesthesiologists (ASA) classification II (P ≤ .001), ASA III (P ≤ .001), or diagnosed with obstructive sleep apnea (P ≤ .001). A total of 34 subjects experienced an adverse outcome (4.07%), though there was no significant difference in the incidence of adverse outcomes between age groups (P = .152). In bivariate analysis, hypertension on medication (P = .037), procedure type (P = .001), and segmented Le Fort I osteotomies (P = .039) were associated with adverse outcomes. After controlling for age, hypertension on medication, segmented Le Fort I osteotomies, and diagnosis of obstructive sleep apnea, isolated mandibular osteotomies were the only independent predictors of adverse outcomes (odds ratio 2.64; 95% confidence interval, 1.06 to 7.24; P = .038). Length of stay was 1.38 ± 1.43 days for the 40 years or older group compared to 1.06 ± 1.18 in the <40 group (P = .012). CONCLUSIONS: Despite higher ASA classifications, older patients did not have a significantly greater incidence of perioperative adverse outcomes including airway complications, nor was increased age associated with adverse outcomes in bivariate or multivariate analysis.

Sclerostin Immunohistochemical Staining in Aggressive Maxillofacial Giant Cell Lesions: Initial Results and Potential Therapeutic Target.

INTRODUCTION: Maxillofacial (MF) giant cell lesions (GCLs) are benign, often locally aggressive lesions with potential for recurrence. Systemic treatments have included interferon alpha, calcitonin, bisphosphonates, and denosumab. Sclerostin (SOST) is typically thought to be a negative regulator of bone metabolism and anti-SOST agents have been used to treat osteoporosis; however, its role in central giant cell granuloma is unknown. The purpose of this study was to evaluate the expression of SOST in MF GCLs. MATERIALS AND METHODS: This was a retrospective study of patients with MF GCLs treated at a single institution between 1993 and 2008 with a minimum follow-up of 6 months. Representative tissue was used to create a tissue microarray and SOST immunohistochemical (IHC) staining and grading was performed. The primary outcomes were IHC staining of the stromal cells and giant cells. The secondary outcomes included correlation of IHC staining and patient predictor variables including clinically benign and aggressive lesions. All analyses were completed using univariate statistical tests. RESULTS: A total of 37 subjects were included (29 clinically aggressive and 8 clinically benign). Sclerostin staining was present in 30 of 37 subjects (81%). Of these, 22 (60%) had stromal cell staining and 28 (76%) had giant cell staining. The presence or absence of staining, of either cell type, was not associated with aggressiveness, presence of clinical symptoms, tumor size, previous interferon therapy, previous surgery, or the race or age of the patient. DISCUSSION: Maxillofacial GCLs have an overall high level of SOST staining; however, the role of SOST in treatment and prognosis is unknown and warrants further study.

Is Outpatient Management of Mandibular Fractures Associated With Inflammatory Complications? An ACS-NSQIP Study.

PURPOSE: Timing of mandibular fracture repair has long been debated. The purpose of the present study was to assess the incidence of postoperative inflammatory complications (POICs) following open repair of mandibular fractures managed non-urgently in the outpatient setting versus urgently in the inpatient setting. METHODS: The authors utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to enroll a sample of patients with mandibular fractures who underwent open repair. The primary independent variable was treatment protocol: outpatient (elective) versus inpatient (urgent/non-elective). The primary dependent variable was POIC (yes/no). Descriptive, bivariate, and multiple logistic regression statistics were utilized to evaluate the relationship between treatment protocol and POICs. RESULTS: The study cohort was comprised of 1,848 subjects with 1,134 outpatients and 714 inpatients. The incidence of POICs was 6.53% for the outpatient group compared to 8.96% for the inpatient group, with no significant difference between groups (P= .052). However, subjects treated as inpatients were 1.51 times more likely to experience any complication (P = .008) due to an increase in non-POICs (P = .028), in particular urinary tract infections (P = .035). After adjusting for age, hypertension requiring medical treatment, and smoking, classification as ASA II (P = .046, OR = 2.21, 95% CI 1.01 to 4.83), ASA III (P = .020, OR = 2.88, 95% CI 1.18 to 7.02), diabetes (P = 0.004, OR = 3.11, 95% CI 1.43 to 6.74), and preoperative hematocrit (P = 0.010, OR = 0.950, 95% CI 0.913 to 0.988) were independent predictors of POICs. Length of stay was 0.83 ± 2.61 days compared to 2.36 ± 3.63 days for the outpatient and inpatient groups, respectively (P ≤ .001). CONCLUSIONS: There was no significant difference in POICs between patients treated as outpatients versus inpatients, though outpatients had fewer non-POICs and a shorter length of hospital stay.

What Factors Are Associated With Open Treatment of Pediatric Mandibular Fractures?

PURPOSE: There is a paucity of data with respect to management of pediatric facial fractures. The purpose of this study was to describe the population of pediatric patients with mandibular fractures at our institution and to assess predictors of fractures requiring open reduction and internal fixation (ORIF). PATIENTS AND METHODS: This was a retrospective cohort study of patients aged ≤17 years presenting with mandibular fractures. The primary predictor variable was age ≥13 years and <13 years. The primary outcome variable was ORIF (yes or no). Epidemiologic factors and complications were also assessed. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between predictor variables and ORIF. RESULTS: The study sample was composed of 84 subjects with 61 subjects aged ≥13 years and 23 subjects aged <13 years. ORIF was used for 21.4% of subjects. Increased age was associated with ORIF (P = .009). After adjusting for the effects of concurrent variables, age (P = .047, OR = 2.30, 95% CI = 1.01 to 5.24), fracture displacement between 2 and 4 mm (P = .032, OR = 18.1, 95% CI = 1.29 to 254), fracture displacement >4 mm (P = .019, OR = 16.9, 95% CI = 1.60 to 179), and the presence of 3 fractures (P = .027, OR = 30.8, 95% CI = 0.001 to 0.641) were positive independent predictors of ORIF. Concomitant facial, skull, or skull base fractures (P = .039, OR = 0.027, 95% CI = 0.001 to 0.641) were a negative independent predictor of ORIF. Secondarily, both mechanism of injury and fracture location varied significantly by age and gender. Complication rate was 6.33%. CONCLUSIONS: Most pediatric mandibular fractures were managed nonoperatively. Increased age, fracture displacement, presence of 3 fractures, and concomitant craniofacial injuries were independent predictors of ORIF. Complication rates were low regardless of treatment modality.

Lemierre Syndrome: Unusual Presentation With Superior Ophthalmic Vein Thrombosis.

ABSTRACT: Lemierre syndrome (LS) is a rare, but serious condition most commonly associated with oropharyngeal bacterial infection. Infection results in thrombophlebitis of the internal jugular vein and its tributaries. It usually affects previously healthy young adults. The authors report an unusual case of an elderly patient with penicillin allergy who developed Lemierre syndrome from an odontogenic infection (Streptococcus intermedius) resistant to clindamycin. She developed thrombosis of the internal jugular vein and superior ophthalmic vein resulting in visual changes. Treatment required incision and drainage, intravenous antibiotics and anticoagulation. Antibiotics were tailored to culture and sensitivities after testing response to a beta-lactam. With antibiotic resistance increasing, investigation of penicillin allergies is warranted for severe head and neck infections.

Comparing Load-Sharing Miniplate and Load-Bearing Plate Fixation in Atrophic Edentulous Mandibular Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: To critically examine reported data to compare patient outcomes between load-sharing and load-bearing plate fixation for edentulous mandibular fractures. MATERIALS AND METHODS: A systematic review and meta-analysis were designed to test the null hypothesis of no difference in postoperative outcomes between load-sharing and load-bearing plate fixation in atrophic, edentulous mandibular fractures. The PubMed, EMBASE, Cochrane Library, Elsevier text mining tool database, and clinicaltrials.gov trial registries were queried up until July 2016. The quality of evidence was determined using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS: A total of 1212 studies were screened for inclusion of which we included 1 high-quality Cochrane review, 6 narrative reviews, and 21 publications of case reports and case series. Overall, the quality of evidence was low. No difference was found between load-bearing and load-sharing fixation in functional recovery, nonunion, or infection. An uncontrolled case series portrayed complete functional and morphological restoration in 96.9% of patients (83.2-99.5; 95% confidence interval) in load-bearing osteosynthesis while another demonstrated the same outcome in only 40.0% of patients (17.5-65.0; 95% confidence interval). CONCLUSIONS: The authors did not find a statistically significant difference between load-bearing and load-sharing plate fixation in edentulous atrophic mandibular fracture patients; although this finding may be influenced by type 2 statistical error. Surgeons should continue to use their best clinical judgment in deciding on treatment approach for these challenging fractures. Future studies with higher level evidence are necessary to guide optimal fracture management.

Characteristics of National Malpractice Claims in Oral and Maxillofacial Surgery.

PURPOSE: Insight into the causes and outcomes of malpractice claims against surgeons will help inform practitioners and may support better patient care. The purpose of this study was to characterize national malpractice claims against oral and maxillofacial surgeons (OMSs). MATERIALS AND METHODS: A comprehensive review of all claims against OMSs from 2000 to August 2018 in the National Practitioner Data Bank was performed. Primary outcomes were claims against OMSs, payment amount, claim duration, and percentage of anesthesia-related claims. Other variables of interest included demographic characteristics, nature of allegations, clinical outcome of injury, outcome of claim, and number of payments of $1 million or greater ("catastrophic payments"). Student t tests and Wilcoxon rank-sum test were performed, and P < .05 was considered significant. RESULTS: This was a retrospective cohort study of malpractice claims against OMSs. There were 2,643 claims against OMSs during the study period. The average age of the claimant was 35.5 ± 18.4 years, and 47.6% were female patients. Most claims (94.7%) were settled out of court for a mean of $130,824 ± $402,633.8. Court-adjudicated claims had significantly higher payments with a mean of $247,554.69 ± $414,655.51 (P < .0001). The average duration from time of event to conclusion of claim was significantly shorter for settled claims (3.5 ± 2.3 years) than for claims that were court adjudicated (5.2 ± 2.7 years) (P < .0001). Anesthesia-related claims made up 3.63% of the total, and 0.56% of claims were pediatric anesthesia related. Anesthesia-related payments were significantly higher than other claims (P < .0001). The most common type of allegation was "surgery-related" injuries (63.1%), followed by "treatment-related" injuries (22.2%). The most common clinical outcome was minor permanent injury (34.6%). CONCLUSIONS: Most claims against OMSs were settled. Only a small portion of claims were associated with anesthesia complications, but payment amounts for these were significantly higher than for other claims. Settlements were made more quickly and for significantly lower rewards compared with judgments. Claims against OMSs during the past 2 decades were most commonly associated with minor permanent injuries occurring in the outpatient setting.

Do Speakers Fully Disclose Potential Conflicts of Interest in Oral and Maxillofacial Surgery?

PURPOSE: The complete disclosure of conflicts of interest is critical to providing objective and ethical continuing education. The purpose of this study was to determine the accuracy of the disclosed financial relationships by speakers at an annual oral and maxillofacial surgery conference. MATERIALS AND METHODS: This retrospective cross-sectional study compared speakers' disclosures on the American Association of Oral and Maxillofacial Surgery Dental Implant Conference 2018 website to the payments reported on the Center for Medicare and Medicaid Services Open Payments Database. The predictor variable was the number of companies reported by the speakers. The outcome variable was the number of relevant companies discovered on the Open Payments Database. Other variables evaluated included total dollar sum transferred and the type of speaker (oral and maxillofacial surgeon (OMS) vs non-OMS). Companies providing payments to speakers on the Open Payments Database were deemed relevant if they had provided goods or services relevant to dental implants. Descriptive statistics were computed, and the Student t test was performed, with P < .05 considered to indicate statistical significance. RESULTS: A total of 43 speakers were included (32 OMSs; 74.4%). We found that 35 of the 43 speakers (81.4%) had received payments relating to dental implants on the Open Payments Database that had not been disclosed on the conference website. On average, the speakers disclosed 0.65 ± 1.04 companies; however, 2.51 ± 1.32 relevant companies per speaker were reported on the Open Payments Database (P < .0001). The OMS speakersdisclosed 0.47 ± 0.95 company on the conference site but had 2.47 ± 1.32 companies reporting payments on the Open Payments Database (P < .0001). Non-OMS speakers disclosed 1.18 ± 1.17 companies, with 2.64 ± 1.36 companies listed on the Open Payments Database (P = .0044). CONCLUSIONS: Continuing education conferences offer an avenue of knowledge transfer; however, the objectivity of the information presented could be affected by undisclosed conflicts of interest. The results from the present study have demonstrated that most speakers at an annual oral and maxillofacial surgery conference have underreported payments from companies relevant to the conference topic.

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part I-Mandibular Fractures.

PURPOSE: The purpose of this study was to determine whether the timing of mandibular fracture repair within the academic year affects the complication rate using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. MATERIALS AND METHODS: The ACS-NSQIP database was accessed and queried from 2008 to 2017 for all Current Procedural Terminology codes pertaining to open treatment of mandibular fractures. The cases were stratified into 2 groups based on academic quarter: the quarter 1 (Q1) group (July-September) and the remaining-quarters group. The inclusion criteria encompassed all Current Procedural Terminology codes in the ACS-NSQIP registry that defined mandibular fractures and age greater than 18 years. Demographic characteristics, as well as medical and surgical complications, were compared between the 2 cohorts. Descriptive statistics were calculated to characterize and compare patient cohorts, and Fisher exact test and χ2 analyses were performed to compare complication rates between groups. RESULTS: The Q1 group included 614 cases, and the remaining-quarters group included 1,454. The most common individual complications included wound dehiscence (1.6% overall; 2.1% in Q1 group vs 1.4% in remaining-quarters group, P = .22), combined superficial and deep-space infection (4.9% overall; 4.4% in Q1 group vs 3.3% in remaining-quarters group; P = .91 and P = .21, respectively), and reoperation (3.9% overall; 4.6% in Q1 group vs 3.6% in remaining-quarters group, P = .29). Medical complications including acute kidney injury, venous thromboembolism, urinary tract infection, and sepsis or septic shock were rare (<1%). Complication rates did not significantly differ between the third quarter and the remainder of the year on bivariate analysis. CONCLUSIONS: Our results do not support the idea of a "July effect" regarding postoperative outcomes after mandibular fracture repair. Further studies are needed to elucidate this phenomenon within all procedures under the wide umbrella of the specialty.

Evaluating the July Effect in Oral and Maxillofacial Surgery: Part II-Orthognathic Surgery.

PURPOSE: The purpose of this study was to determine if there is an increased postoperative complication rate in orthognathic surgery during the first academic quarter (Q1) (July to September). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was accessed to identify cases with Current Procedural Terminology codes pertaining to orthognathic procedures from 2008 to 2017. Procedures were separated into 2 groups based on time in the academic year: Q1 (July to September) versus remaining quarters (RQ). The inclusion criteria were Current Procedural Terminology codes representing operations resulting in movement of the dentate portion of the jaws and age of 18 years or older. Patient demographic characteristics and perioperative complications were compared between the groups. Descriptive statistics, Fisher exact tests, and χ2 tests were executed. RESULTS: The Q1 cohort included 877 cases, and the RQ cohort included 2,062 cases. The average age of patients was 47.0 ± 19.5 years in Q1 versus 47.2 ± 19.4 years in RQ. The most frequent complications were blood transfusion (11.97% in Q1 vs 12.57% in RQ, P = .64), reoperation (8.67% in Q1 vs 8.84% in RQ, P = .87), and combined superficial and deep-space infection (5.02% in Q1 vs 5.76% in RQ, P = .51). Medical complications involving other organ systems were rare (<1%). Analyses showed no significance between complication rate and time of year. CONCLUSIONS: The results of this study indicate that there is no association between time of year and complication rates after orthognathic surgery. Additional investigations could be useful in shining light on this topic as it pertains to the training of future surgeons.

Can Patients With Isolated Mandibular Fractures Be Treated as Outpatients?

PURPOSE: Treating mandibular fractures urgently is controversial. The purpose of this study was to estimate and compare the rates of postoperative inflammatory complications (POICs) in patients with isolated mandibular fractures treated in a nonurgent manner by an outpatient protocol versus a traditional, urgent inpatient protocol. PATIENTS AND METHODS: We implemented a retrospective cohort study and enrolled a sample of patients with isolated mandibular fractures treated with open reduction-internal fixation (ORIF). The primary predictor variable was the treatment protocol: outpatient (elective) or inpatient (urgent). The outpatient group was treated with closed reduction and intermaxillary fixation, discharged, and scheduled for definitive treatment as outpatients. The inpatient group was admitted to the hospital, and the fracture was treated with ORIF as soon as possible. The primary outcome variable was POIC (present or absent). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between the treatment protocol and POICs, with statistical significance set at P < .05. RESULTS: The study sample was composed of 193 patients, with 82 in the outpatient group and 111 in the inpatient group. The frequency of POICs was 17.1% and 18.9% in the outpatient and inpatient groups, respectively (P = .13; relative risk, 0.80; 95% confidence interval [CI], 0.62 to 1.0). The time to ORIF was not significantly associated with POICs (P = .71). After adjustment for treatment group, fracture location, and time to fracture stabilization, smoking (P = .04, odds ratio, 2.3; 95% CI, 1.0 to 5.1) and intraoral incision with a transbuccal trocar (P = .02, odds ratio, 3.4; 95% CI, 1.2 to 9.8) were associated with an increased risk of POICs. Length of stay was 0.6 ± 0.8 days in the outpatient group compared with 2.7 ± 2.0 days in the inpatient group (P < .0001). CONCLUSIONS: An outpatient model to treat isolated mandibular fractures was not associated with an increased risk of POICs. This outpatient care model reduced the hospital length of stay without increasing the risk of POICs.

Variability in Current Procedural Terminology Codes for Craniomaxillofacial Trauma Reconstruction: A National Survey.

BACKGROUND: Current Procedural Terminology (CPT) codes are an important part of surgical documentation and billing for services provided within the United States. This limited coding language presents a challenge in the heterogenous and rapidly evolving field of craniofacial surgery. The authors aimed to survey members of the American Society of Maxillofacial Surgery (ASMS) to characterize the variability in coding practices in the surgical management of craniofacial trauma. METHODS: A cross-sectional of 500 members of the ASMS survey was carried out. Descriptive statistics were calculated. The effect of various practice characteristics on coding practices was evaluated using Chi-squared tests and Fisher's exact tests. RESULTS: In total, 79 participants responded including 77 plastic surgeons. About 75% worked in academic centers and 38% reported being in practice over 20 years. Coding practices were not significantly associated with training background or years in practice. Unilateral mandibular and unilateral nasoorbitoethmoid fractures demonstrated the greatest agreement with 99% and 88% of respondents agree upon a single coding strategy, respectively. Midface fractures, bilateral nasoorbitoethmoid fractures, and more complex mandibular demonstrated considerable variability in coding. CONCLUSION: There is a wide variability among members of the ASMS in CPT coding practices for the operative management of craniofacial trauma. To more accurately convey the complexity of craniofacial trauma reconstruction to billers and insurance companies, the authors must develop a more descriptive coding language that captures the heterogeneity of patient presentation and surgical procedures.