Geriatric Craniomaxillofacial Fractures: Where do They Happen and Why?

PURPOSE: The geriatric population is a constantly growing population that is especially vulnerable to trauma. The primary purpose of this study was to determine what factors are associated with increased rates of hospital admission in geriatric patients who sustain craniomaxillofacial fractures secondary to falls. MATERIALS AND METHODS: This is a 5-year retrospective cross-sectional study that was conducted using the NEISS database. There were several, heterogenous predictor variables. The primary outcome variable was admission rate, which was used as a proxy to the severity of injury. Patient and injury characteristics were compared using chi-square and independent-sample t-tests. Binary logistic regression was conducted to determine the risk of hospital admission. RESULTS: The final sample included 2,879 cases in total. The mean age of the study sample was 78.8 years (SD, 8.6 years). Most patients were white (51.6%) females (64.2%) who were injured at their respective homes (58.7%). Relative to injuries that took place at a sports center, injuries that took place at the patient's home (OR, 2.52; P < .05) independently increased the risk for admission. Relative to maxilla fracture, orbital bone fracture (OR, 3.91; P < .05) was an independent risk factor for admission. Relative to lacerations, intracranial injuries (OR, 3.76; P < .01) increased the risk of admission. CONCLUSIONS: Craniomaxillofacial fractures that took place at the patients' home were at increased risk for admission. Orbital bone fractures and intracranial injuries were at increased risk for admission. From our, and other studies findings, screening and fall prevention interventions should be implemented amongst the geriatric population.

What are the Risk Factors for Mortality Among Patients Who Suffer Le Fort III Fractures?

PURPOSE: Le Fort III fractures are the most severe subtype of the Le Fort fractures and are associated with adverse clinical outcomes. The purpose of this study was to identify risk factors for mortality among patients who suffer Le Fort III fractures. MATERIALS AND METHODS: A retrospective cohort study was completed using the 2016-2018 National Inpatient Sample. Patients with isolated Le Fort III fractures were selected. Patients who incurred bone fractures or organ injuries outside the head and neck were excluded. There were multiple, heterogenous predictor variables. The primary outcome variable was mortality. Relative risk was used to determine independent risk factors of mortality. Statistical significance was deemed for P values less than .05. RESULTS: The final sample consisted of 559 patients (mean age, 45.9 years) who suffered a Le Fort III fracture, of whom 15 patients (2.68%) died. Most patients were male (82.7%) middle-aged adults (42.9%) of White race (66.5%) within the lowest income quartile (31.7%) that lived in large metro areas (54.9%). Relative to males, females were nearly 62 times more likely to die (P < .01). Relative to privately insured subjects, uninsured subjects were 23 times (P < .05) more likely to die. Relative to weekday admissions, weekend admissions increased the risk of mortality by 8 times (P < .05). Cranial vault fractures (odds ratio, 7.24; P < .05) and upper cervical fractures (odds ratio, 63.27; P < .05) were risk factors for mortality. Relative to males, females were at an increased risk for mortality (relative risk [RR] 7.14, 95% confidence interval [CI] 2.60, 19.61). Skull base fracture (RR 2.99, 95 CI 1.04, 8.63), cranial vault fracture (RR 3.04, 95 CI 1.07, 8.65), subdural hemorrhage (RR 2.98, 95 CI 1.10, 8.05), subarachnoid hemorrhage (RR 6.73, 95 CI 2.34, 19.35), and injury of blood vessels at neck level (RR 13.24, 95 CI 2.46, 71.16) were each risk factors for mortality. CONCLUSIONS: Intracranial injury was not a risk factor for mortality. Instead, cranial vault fractures and skull base fractures increased the risk for mortality. In addition, uninsured patients and female patients were each at an increased risk for mortality.

Three-Dimensional Repositioning of the Maxilla in Orthognathic Surgery Using Patient-Specific Titanium Plates: A Case Series.

PURPOSE: Successful orthognathic surgery is fundamentally based on accurately carrying out the intended surgical plan intraoperatively. The purpose of this study was to evaluate the accuracy of bone-borne patient-specific maxillary cutting guides and 3-dimensional (3D)-printed plates in repositioning the maxilla during bimaxillary orthognathic surgery. MATERIALS AND METHODS: This was a retrospective case series consisting of patients who had undergone Le Fort I osteotomy with a patient-specific cutting guide and 3D-printed plate as well as a bilateral sagittal split osteotomy and had 6-week postoperative cone-beam computed tomography studies. The primary outcome variable was the difference between the position of the postoperative maxilla and the virtually planned maxilla measured at 10 landmarks in 3 dimensions. Other study variables included the preoperative diagnosis and planned surgical movement at each landmark. Descriptive statistics were tabulated, and bivariate analyses were performed. RESULTS: A total of 10 patients were included in this study. The mean age was 25.7 ± 8.1 years, and there were 5 female patients. The median planned surgical movement was 0.350 mm on the x-axis (right-left), 3.750 mm on the y-axis (anterior-posterior), and 1.704 mm on the z-axis (superior-inferior). The median absolute discrepancy between the postoperative position and the planned position on the x-axis, y-axis, and z-axis was 0.638, 0.798, and 0.481 mm, respectively. There was no significant difference in the discrepancies between the x-axis and y-axis (P = .575), x-axis and z-axis (P = .332), and y-axis and z-axis (P = .114). CONCLUSIONS: Using a patient-specific cutting guide and 3D-printed plate when performing Le Fort I osteotomy allows for accurate 3-dimensional positioning of the maxilla in accordance with the surgical plan.

Resorbable Mesh as a Containment System in Mandibular Reconstruction.

The recent advances seen in computer technologies and biomaterials have changed the approach to craniomaxillofacial surgery. In this report, the authors describe the technique of using a resorbable containment system for bone graft in a large mandibular reconstruction patient. The authors provide a patient report with a 1-year follow-up.

Surgeon and advocate: identifying intimate partner violence from craniomaxillofacial injuries.

OBJECTIVES: Intimate partner violence (IPV) has been recognized as a preventable public health crisis for over 20 years. Craniomaxillofacial (CMF) injuries are exceedingly common among victims of IPV. The objective of this study was to determine whether assault due to IPV is different than other types of assault. STUDY DESIGN: A retrospective cohort study using data from the Nationwide Inpatient Sample data sets from 2016 to 2018. Additionally, the case control was matched for age, sex, and race for patients within the initial sample of assault patients (n = 52,632). RESULTS: Our final study sample consisted of 1,114 patients. Patients with IPV were less likely to have concussions (1.7 vs 3.6%; P < .01) and traumatic subarachnoid hemorrhages (2.1 vs 4.1%; P < .01), but more likely to have diffuse traumatic brain injuries (26.1 vs 18.7%; P < .01). Patients with IPV were less likely to have schizoaffective disorder (1.5 vs 2.8%; P < .05) but were more likely to have depressive episodes (19.8 vs 13.6%; P < .01), major depressive disorder (10.7 vs 5.3%; P < .01), and adjustment disorder (4.8 vs 2.2%; P < .01). CONCLUSIONS: We found that victims of IPV would be more likely to be female, delay care, have a mental health diagnosis, and present with worse intracranial injuries than other forms of assault. We hope our study informs and empowers maxillofacial surgeons to be a vigilant member of the interdisciplinary team.

Physician attire in the military setting: does it make a difference to our patients?

OBJECTIVE: To examine patient preference regarding physician attire and whether perception of medical competence was influenced by the physician's clothing style. METHODS: New patients presenting to the OB/GYN clinic at the Naval Medical Center Portsmouth were asked to complete a survey regarding patient preference for physcian attire and any effect on their comfort or confidence in the physician. RESULTS: Surveys were collected over a 2-month period. Completed surveys (328) were analyzed with the following results: 86% had no preference whether the physician wore a white coat, 61% preferred scrubs, 13% were uncomfortable talking to a doctor about general topics, and 16% were uncomfortable talking about sexual, psychological, or personal topics based on physician attire. In a comparison between active duty women and dependent wives, a significantly greater number of dependent wives reported the physician attire having no influence on their comfort level discussing general topics with their physician (p = 0.037) or about sexual, psychological, or personal topics (p = 0.035). No difference was seen between groups in the preference to wear a white coat (p = 0.196) or other attire (p = 0.088) or of an influence of the doctors' clothing on the patient's confidence in the doctors' abilities (p = 0.063). CONCLUSION: Overall, female patients in a military setting do not have a preference for specific physician attire and attire does not influence their perception of the doctor's competence. However, a greater number of dependent wives report physician attire has no influence on their comfort level discussing both general and personal topics when compared with active duty women. This finding highlights the unique role of the military uniform in the eyes of active duty women and their potential discomfort in discussing personal medical issues with a physician in military uniform.

Viral mumps: Increasing occurrences in the vaccinated population.

Before the introduction of the vaccine, mumps was the most common salivary gland disease and was one of the most common infectious diseases in children globally. Following the introduction of the mumps vaccine in 1967, the disease was almost nonexistent in the United States and was only found to occur in nonvaccinated patients, and even then, it did not present in epidemic portions because of the extent of vaccination in the population at large. Beginning in the early 2000s, viral mumps began to present itself in vaccinated populations, and currently, outbreaks are continuing to increase in number. This article presents information on the various outbreaks, a review of the virus and the disease, including symptoms and comorbidities, and new recommendations for management. Dental practitioners should be aware of the increasing incidence and prevalence of this disease, be able to recognize it, and make appropriate referrals for management.

Dry mouth and its effects on the oral health of elderly people.

BACKGROUND: The objective of this literature review is to summarize information about the etiology, diagnosis, oral sequelae and treatment of dry mouth in elderly patients. TYPES OF STUDIES REVIEWED: The authors conducted a comprehensive review of the English-based scientific literature from the past 10 years. They selected the studies on the basis of clinical investigations to provide an objective assessment of dry mouth problems among older people. RESULTS: Dry mouth (salivary hypofunction, xerostomia) is a common problem among older people. It causes significant oropharyngeal disorders, pain and an impaired quality of life. Dry mouth has many causes, from local salivary disorders to a plethora of medications and medical conditions. Treatments are designed to correct the underlying cause and/or to enhance salivation with topical and systemic stimulants. Early intervention for dry mouth problems helps prevent the deleterious consequences of this disorder in elderly people. CLINICAL IMPLICATIONS: Clinicians must be aware of dry mouth problems in older patients, and they should be prepared to provide a diagnosis and administer treatment to protect a patient's oropharyngeal health and quality of life.

The recognition, physiology, and treatment of medication-induced methemoglobinemia: a case report.

Dapsone is a leprostatic agent commonly prescribed for the management of leprosy, malaria, and the immunosuppression-induced infections of Pneumocystis carinii and Toxoplasma gondii. In susceptible patients, methemoglobinemia, a potentially life-threatening event, can occur. We report a case of dapsone-induced methemoglobinemia which was observed during general anesthesia for the management of a fractured mandible. The pathophysiology, diagnosis, and management of dapsone-induced methemoglobinemia will be discussed.

Sialoendoscopy: A new approach to salivary gland obstructive pathology.

BACKGROUND: During the last 13 years, there has been a growing interest in and use of minimally invasive treatment techniques. Salivary gland endoscopes provide an accurate means of diagnosing and providing minimally invasive surgical treatment for salivary gland diseases. METHODS: The authors review the relevant literature and provide the history of sialoendoscopy. They also report on the treatment methods they use, including instruments and techniques, and their experiences. RESULTS: The authors' overall success rate for parotid endoscopic sialolithotomy is 86 percent, and their overall success rate for submandibular endoscopic sialolithotomy is 89 percent. Their success rate for treating strictures is 81 percent. CLINICAL IMPLICATIONS: The endoscopic technique opens new horizons in the field of salivary gland diseases. Salivary gland stones and sialadenitis no longer are absolute indications for sialadenectomy. Owing to growing experience and surgical skills, new endoscopic techniques are in clinical use, and there is constant improvement in endoscopic treatment success rates. CONCLUSIONS: Sialoendoscopy is a promising new method for use in the diagnosis, treatment and postoperative management of sialadenitis, sialolithiasis and other obstructive salivary gland diseases.

Dental management of the gravid patient.

Gravidity is defined as the development of the young in utero. It initiates hormonal, psychological and physiological changes in the female patient, providing the dentist with many questions about the management of these patients. These physiologic alterations, as well as the embryologic development of the fetus, will be discussed along with the treatment alterations that should be considered. The changes are often subtle, but can lead to disastrous complications if proper precautions are not taken. Conversely, appropriate management of routine and dental emergencies can be denied by the practitioner because of misconceptions about pregnancy and fetal tolerance. Anesthetic and pharmacology of agents used in dentistry in treating the pregnant patient will be reviewed.

Hyposalivation and Xerostomia: Etiology, Complications, and Medical Management.

Saliva is one of the most versatile, multifunctional substances produced by the body and has a critical role in the preservation of the oropharyngeal health. It comprises a serous and mucinous component and is secreted by the major salivary glands. The mucins in the saliva serve to protect and lubricate the hard and soft tissues of the mouth, protecting them from chemical and mechanical damage. Hyposalivation can be managed by various salivary substitutes, peripheral sialagogues, and central sialagogues.

Salivary gland disease in Sjögren's syndrome: sialoadenitis to lymphoma.

Although the cause and molecular pathways of Sjögren's syndrome are still unknown, basic, clinical, and translational science have started to identify linkages to other known processes. With the advent of newer, more sensitive, and more accurate chemokine, cytokine, and genetic analysis, the molecular progression of the disease may be understood. The modern technology of sialoendoscopy to treat obstructive sialoadenitis from mucous plugging, and the addition of rituximab to current chemotherapy, have allowed patients with Sjögren's syndrome to have a better quality of life and, if they develop lymphomatous changes, a significant increase in their disease remission and survival rate.

Sialoendoscopy and salivary gland sparing surgery.

Obstructive disease and chronic infections often are managed by extirpative gland surgery. With the advent of new technology and better understanding of salivary physiology, minimally invasive surgical techniques provide the opportunity for safer and less invasive surgery in alternative care settings and the prospect for gland sparing and restoration of normal function. This article describes techniques for managing acute and chronic salivary gland infections using sialoendoscopy.