Sports-Related Maxillofacial Injuries.

BACKGROUND: Sports-related maxillofacial injuries contribute a significant proportion of the workload in a maxillofacial unit. The aim of this study was to identify the incidence of maxillofacial sports-related injuries, treatments required, and assess the impact of the injury on future sport participation. METHOD: A retrospective review was carried out on all maxillofacial trauma referrals from September 1, 2009 to August 31, 2010. Patient records were reviewed and the following variables were recorded: age, sex, sport involved, injury sustained, mechanism of injury, treatment, subsequent participation, and interval before return to sport. RESULTS: The study population included 162 patients with sports-related facial injuries. The most common sporting injuries were as follows: Gaelic football 35.3% (N = 57), soccer 22.3% (N = 36), rugby 12.4% (N = 20), and equine sports 12.4% (N = 20). The most common injury sustained was zygomatic complex fracture 36.4% (N = 59). Mandibular fracture occurred in 20% (N = 33), orbit fracture in 14.2% (N = 23), and nasal bone fracture in 12.3% (N = 20). The most common mechanism of injury was from a clash of heads (23.4%) followed by an elbow to the face (17.2%). The majority of patients (84%) resumed participation in their chosen sport at mean interval of 7.3 weeks (range 1-18 weeks). CONCLUSIONS: This study identified a significant number of sporting facial injuries, which presented over 1 year. In total, 113 patients underwent a surgical procedure for the management of their injuries. This study highlights the need to educate all players regarding use of personal protective equipment and adherence to the rules of sports.

Does access to general dental treatment affect the number and complexity of patients presenting to the acute hospital service with severe dentofacial infections?

AIM: This is a retrospective study to review the treatment and management of patients presenting with odontogenic infections in a large urban teaching hospital over a four-year period, comparing the number and complexity of odontogenic infections presenting to an acute general hospital in two periods, as follows: Group A (January 2008 to March 2010) versus Group B (April 2010 to December 2011). The background to the study is 'An alteration in patient access to primary dental care instituted by the Department of Health in April 2010'. OBJECTIVES: a) to identify any alteration in the pattern and complexity of patients' presentation with odontogenic infections following recent changes in access to treatment via the Dental Treatment Services Scheme (DTSS) and the Dental Treatment Benefit Scheme (DTBS) in April 2010; and, b) to evaluate the management of severe odontogenic infections. METHOD: Data was collated by a combination of a comprehensive chart review and electronic patient record analysis based on the primary discharge diagnosis as recorded in the Hospital In-Patient Enquiry (HIPE) system. RESULTS: Fifty patients were admitted to the National Maxillofacial Unit, St James's Hospital, under the oral and maxillofacial service over a four-year period, with an odontogenic infection as the primary diagnosis. There was an increased number of patients presenting with odontogenic infections during Group B of the study. These patients showed an increased complexity and severity of infection. Although there was an upward trend in the numbers and complexity of infections, this trending did not reach statistical significance. CONCLUSIONS: The primary cause of infection was dental caries in all patients. Dental caries is a preventable and treatable disease. Increased resources should be made available to support access to dental care, and thereby lessen the potential for the morbidity and mortality associated with serious odontogenic infections. The study at present continues as a prospective study.

Broken needle: a rare complication of inferior alveolar nerve block - a report of two cases.

Introduction Needle fracture during the delivery of local anaesthesia is a rare complication in modern dentistry. While there has been a decline in its occurrence with the advent of disposable flexible alloys, it still occurs and it is important for all clinicians to know how to deal with this complication. The management of a lost needle in the pterygomandibular space when giving an inferior alveolar nerve block has proven a dilemma in the past. In this paper, we discuss how to minimise the risk and the relevant management of such a scenario while examining two cases of needle fracture while delivering an inferior alveolar nerve block.Discussion There are a number of structures present in the pterygomandibular space of which all clinicians should be cognisant. Should a needle fracture and cannot be removed immediately by the clinician, prompt maxillofacial referral is required for further management.Conclusion While rare, needle fracture can occur while delivering an inferior alveolar nerve block and all clinicians should be aware of how to minimise the risk and how to manage such a complication. If it cannot be removed at the time, a prompt maxillofacial referral should be made.

Maxillofacial fractures in females: a 5-year retrospective review.

BACKGROUND: This retrospective study reviews the maxillofacial fractures (MF) over a 5-year period at the National Maxillofacial Unit, St James Hospital Dublin, with an emphasis on female patients. MATERIALS AND METHODS: The trauma database was analysed from January 2015 to December 2019. The following demographic details were recorded: patient age and gender, mechanism of injury, and facial fracture sites. This retrospective study did not require approval from the local IRB. RESULTS: A total of 4761 patients had facial fractures during the study: 1125 (24%) female, 3636, (76%) male. Females had 1190 facial fractures, with two fracture peaks: 20-39 years and 70-89 years. In males, the majority of fractures occurred between 20 and 39 peaking at 20-29 years and tailed off thereafter. In the females the most common fracture sites were zygomatic 402 (34%), nasal 311(26%), orbital (22%), and mandibular 141(12%). There were also smaller percentages of frontal (0.8%), maxillary (4%), and Le Fort fractures (1%). Two hundred and sixty-two (23%) females were managed surgically and 853 (77%) non-surgically. CONCLUSION: This study confirms maxillofacial fractures are less common in females. The female age distribution demonstrates two peaks, one in early adult and a second in old age. This may be explained by females living longer and independently and at risk for falls. The most commonly reported fracture aetiology in females was "falls." This raises concerns as to whether "falls" are used to explain an assault. There is an informal concern amongst maxillofacial surgeons that females presenting with facial trauma may be the victims of domestic violence, which may be denied by the victims.

The use of 3D printing technology in the creation of patient-specific facial prostheses.

BACKGROUND: Personalised medicine aims to optimise patient outcomes by tailoring treatments and interventions to the individual. While this approach can offer a number of benefits, it can be accompanied by significant overheads in terms of resources. Prostheses exist in order to restore and replicate the normal functions and appearance of the body but if these are not individually tailored to the patient's needs then a true restoration cannot be fully achieved. Traditionally a labour intensive process, the fabrication of craniofacial prostheses, involves taking a plaster cast of the area to be treated, hand carving wax models of the restoration and multiple meetings with the patient to alter this wax restoration before making a final prosthesis in silicone. AIMS: Utilising the patient's pre-existing computed tomography (CT) images and 3D printing technology, a patient-specific prosthesis can be created with improved efficiency and accuracy. METHODS: This study demonstrates methods used to create a patient-specific orbital prosthesis using CT images. These images were manipulated in a way which allowed for the intact orbit to be mirrored and used to develop a 3D printed model which acted as the starting point to create a silicone prosthesis. RESULTS: The benefits of using this method include reduced manufacturing time, decreased outpatient appointments, improved personalised outcomes and a repeatable process allowing multiple prostheses to be made. CONCLUSIONS: 3D printing is a valuable tool which can provide significant savings in time and improve patient outcomes by offering a tailored approach to each individual's treatment.

Decision-making in awake fibre optic intubation for patients with severe dentofacial infection: which patients will require fibre optic intubation?

BACKGROUND: Risk factors for advanced airway intervention among patients with dentofacial infection (DFI) are poorly understood. The appropriate delivery of clinical care to this patient group raises challenging anaesthetic service provision issues. The purpose of this study was to identify factors which may predict a requirement for an awake fibre optic intubation (AFOI) technique for airway management in this patient population. METHODS: A retrospective analysis of data for consecutive patients admitted with DFI were analysed at the Oral & Maxillofacial department at St James's Hospital, Dublin from July 2014-July 2015 was carried out. Receiver operating characteristic analysis determined optimal cut-off values predictive of AFOI, and multivariate logistic regression determined independent risk factors for AFOI. RESULTS: One hundred and twenty-five patients (64 male, 61 female) were admitted with DFI. The mean age was 35.9 years (range 16-91). AFOI was carried out in 58 (67.4%) patients who required GA. Increasing age was associated with an increase likelihood of AFOI (P = 0.047 95% CI 1.07(1.00-1.14). Reduced mouth opening was significantly associated with requirement for AFOI (28.8 ± 8.6 vs. 14.8 ± 8.6 mm, P < 0.0001). On receiver operating characteristic (ROC) analysis, mouth opening predicted requirement for AFOI with 87% accuracy (AUC 0.87 [95% CI 0.80-0.95], P < 0.0001). Using a cut-off value of 16.5 mm predicted subsequent AFOI with 96.7% (95% CI 78.1-100.0%) specificity and 65.6% (95% CI 51.4-77.8%) sensitivity. Initial C-reactive protein (CRP) was significantly associated with requirement for AFOI (60.1 ± 40.0 vs. 121.3 ± 89.8, P = 0.002). A CRP value of over 110 mg/L predicted subsequent AFOI with 95.8% (95% CI 78.9-100.0%) specificity. CONCLUSION: Increasing age, reduced mouth opening < 16.5 mm, and an increased serum admission CRP > 100 mg/L on admission significantly increase the requirement for AFOI on multivariate and univariate regression analysis. The availability of anaesthetists experienced in AFOI is essential for safe management of these patients.

The surgical management of severe dentofacial infections (DFI)-a prospective study.

Dentofacial infections (DFI) lead to morbidity and rarely, mortality. We hypothesised that certain clinical and laboratory parameter factors may be associated with a more severe course and an increased length of stay. We designed a prospective study that included all patients admitted with a DFI to the Oral and Maxillofacial Department between July 2014 and July 2015. A total of 125 were enrolled. We found that serum concentration of CRP on admission and increasing number of fascial spaces involved by the infection were significant predictors of hospital stay (p = 0.02 and p = 0.01, respectively). The average length of stay for a dentofacial infection requiring admission was 4.5 days. Most patients require surgical intervention in combination with intravenous antibiotics for successful resolution. Improved and timely access to primary dental care is likely to reduce the burden for patients their families and the acute hospital service as a consequence of advanced DFI.

Ocular findings in patients with orbitozygomatic complex fractures: a retrospective study.

PURPOSE: To evaluate the incidence of ocular injuries and clinical ocular signs in patients with orbitozygomatic fractures of varying severity, presenting to a regional oral and maxillofacial surgery service. PATIENTS AND METHODS: This is a retrospective study of patients presenting to Limerick Regional Hospital (Limerick, Ireland) with orbitozygomatic fractures from January 1998 to December 2004. Patients with panfacial fractures and those with isolated zygomatic arch fractures were excluded. All patients were examined by the ophthalmology service preoperatively and reviewed postoperatively as indicated. The study population was divided into 3 subgroups based on the extent of the bony injury (confirmed by clinical, plain radiographic, and CT examination) as follows: group 1: "simple" noncomminuted orbitozygomatic complex fractures; group 2: comminuted orbitozygomatic complex fractures; group 3: "pure" orbital blowout fractures. Patient demographics, fracture etiology, and ocular findings were recorded. RESULTS: The study population included 148 patients (130 males, 18 females). All fractures were unilateral. Ocular findings were present in 29 (20%) patients, consisting of 8 of 85 patients (9%) in group 1; 15 of 53 patients (28%) in group 2; and in 6 of 10 patients (60%) in group 3. CONCLUSIONS: Clinical ocular findings and injuries are a relatively common complication of orbitozygomatic fractures, occurring in 29 (20%) patients in this study. These injuries occur more often in patients with orbital blowout fractures compared with comminuted orbitozygomatic complex fractures or simple orbitozygomatic complex fractures. Ophthalmology consultation is recommended for all patients presenting with orbitozygomatic fractures, and is essential for patients with orbital blowout fractures, based on the high incidence of clinical ocular findings and injuries in this subgroup of patients.

Maxillary alveolar ridge augmentation using distraction osteogenesis: a literature review and case report.

The restoration of the edentulous atrophic anterior maxillary ridge has proved difficult. The absence of both gingival and bony alveolar tissue contributes to these problems. Numerous techniques to address these issues have been described. We report a case of a patient who sustained multiple facial injuries as a consequence of an accident, including the loss of the maxillary incisor teeth and associated alveolus. This patient underwent fixed implant supported prosthetic rehabilitation, following the use of distraction osteogenesis in the reconstruction of the edentulous atrophic anterior maxillary ridge.

Reconstruction of orbital floor blow-out fractures with autogenous iliac crest bone: a retrospective study including maxillofacial and ophthalmology perspectives.

This is a 10-year retrospective study of patients with an isolated unilateral orbital floor fracture reconstructed with an autogenous iliac crest bone graft. The following inclusion criteria applied: isolated orbital floor fracture without involvement of the orbital rim or other craniofacial injuries, pre-/post-operative ophthalmological/orthoptic follow-up, pre-operative CT. Variables recorded were patient age and gender, aetiology of injury, time to surgery, follow-up period, surgical morbidity, diplopia pre- and post-operatively (Hess test), eyelid position, visual acuity, and the presence of en-/or exophthalmos (Hertel exophthalmometer). Twenty patients met the inclusion criteria. The mean age was 29 years. The mean follow up period was 26 months. No patient experienced significant donor site morbidity. There were no episodes of post-operative infection or graft extrusion. Three patients had diplopia in extremes of vision post-operatively, but no interference with activities of daily living. One patient had post-operative enophthalmos. Isolated orbital blow-out fractures may be safely and predictably reconstructed using autogenous iliac crest bone. The rate of complications in the group of patients studied was low. The value of pre- and post-operative ophthalmology consultation cannot be underestimated, and should be considered the standard of care in all patients with orbitozygomatic fractures, in particular those with blow-out fractures.

Aggressive giant cell lesion of the jaws: a review of management options and report of a mandibular lesion treated with denosumab.

Giant cell lesions (GCLs), previously referred to as giant cell granulomas, are benign tumors of the jaws of unknown etiology. Surgical management of aggressive GCLs is challenging, as these lesions demonstrate a tendency to recur following surgical removal. In addition, surgical treatment can be associated with significant morbidity. In an attempt to reduce both the extent of morbidity and the recurrence rate following surgery, a number of pharmacologic therapies have been advocated on the basis of assumptions about the predominant cell types and receptors, for the management of these lesions. This report describes the use of denosumab, an agent originally used for its anti-resorptive effects, in the management of an aggressive GCL of the mandible in an older patient, who was unsuitable for extensive surgery and in whom treatment with intralesional triamcinolone had proved unsuccessful. Denosumab may be a viable alternative or adjunct to surgery in the management of GCLs of the jaws.

Case report--odontogenic keratocysts: enucleation, bone grafting and implant placement: an early return to function.

The odontogenic keratocyst (OKC) is a developmental odontogenic cyst accounting for approximately 3%-17% of cysts of the jaws. This is an uncommon lesion both clinically and pathologically because of the unusual growth pattern and high tendency for recurrence. The recommended surgical management of the lesion varies from marsupialisation to en bloc resection. In the treatment of a large mandibular OKC, enucleation and immediate bone grafting maintains mandibular integrity, reduces the risk of pathological fracture permits restoration of function with implant-supported prostheses. We recommend the following protocol in the management of large mandibular OKC: 1. Biopsy of the lesion. 2. CT scans in axial and coronal planes. 3. Enucleation of the cyst and removal of the associated teeth. 4. The excision of the overlying mucosa. 5. Immediate mandibular reconstruction with a corticocancellous iliac crest bone graft. 6. Placement of endosseous implants four months following bone grafting. 7. Reconstruction of the dentition six months following implant placement.

Management of large erupting complex odontoma in maxilla.

We present the unusual case of a large complex odontoma erupting in the maxilla. Odontomas are benign developmental tumours of odontogenic origin. They are characterized by slow growth and nonaggressive behaviour. Complex odontomas, which erupt, are rare. They are usually asymptomatic and are identified on routine radiograph but may present with erosion into the oral cavity with subsequent cellulitis and facial asymmetry. This present paper describes the presentation and management of an erupting complex odontoma, occupying the maxillary sinus with extension to the infraorbital rim. We also discuss various surgical approaches used to access this anatomic area.

Superior border plating technique in the management of isolated mandibular angle fractures: a retrospective study of 50 consecutive patients.

PURPOSE: To determine the complication rate for patients presenting with isolated mandibular angle fractures treated by open reduction and internal fixation using a single superior border miniplate technique. PATIENTS AND METHODS: This is a retrospective study of consecutive patients with isolated mandibular angle fractures treated using a specific protocol at a Regional Oral and Maxillofacial Department between January 1998 and December 2004. Patient demographics, fracture etiology, length of hospital stay, removal of third molar, and postoperative complications were recorded. Preoperative and postoperative inferior alveolar nerve function was recorded. Objective sensory testing and patient interviews were conducted to determine the incidence of postoperative sensory deficit. RESULTS: The study population included 50 patients presenting with isolated mandibular angle fractures, 6 patients (12%) experienced complications requiring bone plate removal. These complications were minor and occurred after fracture healing as follows: 4 patients (8%) experienced superficial soft tissue infection associated with the bone plate, treated with oral antibiotics, 1 patient (2%) experienced bone plate exposure, and a further patient (2%) presented with a fractured bone plate. All 6 patients (12%) were treated by bone plate removal under general anesthesia as elective day case surgery. Thirty-nine (78%) patients had long-term sensory follow-up, mean 37 months (2 to 84 months). Permanent inferior alveolar sensory deficit (>12 months) was present in 4 (8%). Five of 26 (19%) patients with normal postinjury/preoperative sensory function had a postoperative sensory deficit. All patients in this group reported recovery of normal sensation within 6 months. CONCLUSIONS: The results of this study suggest that the complication rates associated with the treatment of isolated mandibular angle fractures using a superior border plating technique, in this patient population, is relatively low (12%). The complications were all minor in nature. There was a permanent (>12 months) inferior alveolar sensory deficit in 4 (8%) patients.