Lower Insertional Torque of Fixation Screws for Mandibular Angle Fractures Is Associated With Complications.

BACKGROUND: Open reduction and internal fixation (ORIF) is a common treatment for mandibular angle fractures. It is unknown, however, whether the insertional torque of the fixation screws is a risk factor for postoperative complications. PURPOSE: The purpose of the study was to determine the association between fixation screw insertional torque and postoperative inflammatory complications (POICs). STUDY DESIGN, SETTING, SAMPLE: The authors conducted a prospective cohort study consisting of all adult patients treated with ORIF of mandibular angle fractures using a single six-hole lateral border plate secured with monocortical screws from January 1, 2020, to October 31, 2022, at a large, urban academic hospital. Patients with gunshot wounds, prolonged maxillomandibular fixation, and bilateral angle fractures were excluded. PREDICTOR VARIABLE: The predictor variables were the average and lowest insertional torque of the six screws placed for fixation during ORIF. MAIN OUTCOME VARIABLE: The outcome variable was the presence of POICs, defined as the occurrence of exposed or infected hardware, abscess formation, recurrent swelling/pain, nonunion, osteomyelitis, or fistula formation. COVARIATES: Demographics, medical history, mechanism, diagnosis, and treatment-related variables were also analyzed. ANALYSES: Descriptive and bivariate analyses were performed. A P value of ≤ .05 was considered significant. RESULTS: There were 51 patients included in the study, 37 (72.5%) men, with a mean age of 31.2 ± 10.1 years. POICs occurred in 15.7% of patients. The average insertional screw torque was 46.9 ± 7.8 Ncm, and the mean lowest insertional screw torque per plate was 34.3 ± 10.2 Ncm. The average torque values were not lower in patients who had POICs versus those who did not (45.0 ± 8.6 Ncm vs 48.4 ± 7.6 Ncm, respectively, P = .16). However, the lowest torque value was less in patients who had POICs compared to those who did not (27.5 ± 11.0 Ncm vs 35.6 ± 9.7 Ncm, respectively, P = .04). CONCLUSION AND RELEVANCE: Among patients with mandibular angle fractures treated with ORIF, decreased insertional torque for the lowest of the six screws placed for fixation was associated with complications. While previous studies have shown certain plating schemes have been associated with complications, the quality of fixation also plays a role.

Does Supplemental Regional Anesthesia Decrease Length of Stay and Opioid Use for Patients Undergoing Head and Neck Microvascular Reconstruction?

PURPOSE: The purpose of this study was to compare length of hospital stay and opioid usage among head and neck surgery (HNS) patients treated with and without regional anesthesia for microvascular free-flap donor sites. METHODS: The authors performed a retrospective cohort study for HNS patients undergoing microvascular free-flap reconstruction. The control group received no regional anesthesia. The experimental group had a regional anesthesia nerve block performed immediately before surgery. The primary outcome variable was length of stay, and the secondary outcome variable was total morphine milliequivalents. The data were analyzed using Student t tests, analysis of variance, Mann-Whitney U test, Kruskal-Wallis test, χ2 test, and multiple linear regression. RESULTS: The study sample was composed of 148 patients with a mean age of 58.1 years. The mean length of stay for the control group was 6.74 ± 1.57 days, compared with the experimental group at 5.84 ± 1.01 days (P < .0001). The mean morphine milliequivalent was 256.5 ± 164.6 mg for the control group and 208.9 ± 164.8 mg for the experimental group (P = .56). Importantly, the demographics, pathology spectrum, flap selection, duration of procedure, and complication rate were similar in both groups. CONCLUSIONS: This study demonstrates that for HNS patients undergoing microvascular reconstruction, regional nerve block at the donor site is associated with significantly shorter hospital stays. Although there was a trend toward decreased opioid usage in the regional anesthesia group, these results did not reach statistical significance. Consideration should be given to incorporate regional anesthesia techniques into early recovery after surgery protocols for centers performing high-volume head and neck microvascular reconstruction.

Evidence-Based Clinical Criteria for Computed Tomography Imaging in Odontogenic Infections.

PURPOSE: Odontogenic infections are a common problem in emergency departments and impose a burden on hospital budgets and provider time. Compounding this is the lack of evidence guiding the patient's initial evaluation. The purpose of this study was to derive evidence-based guidelines for the use of computed tomographic (CT) imaging in the management of odontogenic infections. MATERIALS AND METHODS: A prospective cohort study was designed. Patients with an odontogenic infection presenting to the emergency department from November 1, 2016 to November 30, 2017 were eligible for inclusion. The outcome variable was need for CT imaging, which was based on the location of the abscess. The potential predictor variables were demographics, history items, examination findings, and laboratory values. The association between the outcome and predictor variables was determined using classification and regression tree analysis and standard logistic regression analysis. RESULTS: There were 129 patients who met the inclusion criteria and consented to participation. The patients were 53.5% men and the mean age was 42.5 years. The most common fascial spaces involved were vestibular (58.2%), submandibular (18.6%), pterygomandibular (6.2%), buccal (5.4%), and lateral pharyngeal (5.4%). The classification and regression tree analysis identified mandibular inferior border blunting at the body as the best predictor for necessitating a CT scan and identified a mouth opening smaller than 25 mm as the second best predictor. These 2 predictors had an accuracy of 96.9% for needing a CT scan. The logistic regression analysis identified these 2 variables and odynophagia, floor of mouth induration, and white blood cell count as relevant predictors for needing CT imaging. CONCLUSION: The 2 physical examination findings of mandibular inferior border blunting at the body and restricted mouth opening were found to be strongly associated with the need for CT imaging. Further studies should be directed at validating these criteria in larger multicenter studies.

On-Site 3-Dimensional Printing and Preoperative Adaptation Decrease Operative Time for Mandibular Fracture Repair.

PURPOSE: The purpose of this study was to compare the intraoperative time and operating room costs between patients with mandibular fractures treated with traditional adaptation and fixation and patients treated with preadapted plates created with on-site 3-dimensionally printed models. PATIENTS AND METHODS: We designed a prospective comparative cohort study for patients with mandibular fractures. The control group received traditional open reduction and internal fixation of their mandibular fractures. For the patients in the experimental group, a 3-dimensional (3D) model of the fractured mandible was made using an on-site 3D printer. The model then underwent osteotomy, if needed, and the plate was adapted to the model, submitted to sterilization, and implanted in the patient. The primary outcome variable was intraoperative plating time, and the secondary outcome variable was operating room cost. The groups were compared by the Wilcoxon signed rank test. RESULTS: The 38 patients included in the study had a mean age of 39.6 years, and male patients comprised 81.6%. The mean time for intraoperative plate adaptation was 22.8 ± 2.1 minutes in the control group and 6.9 ± 0.3 minutes in the experimental, 3D printed group (P < .0001). In the experimental group, 4 patients (21%) required a single intraoperative corrective bend. The calculated average cost per patient based on the average operating costs at our institution was $2,306.45 in the control group and $698.00 in the experimental group. CONCLUSIONS: This study shows that the use of 3D printers for fabrication of models to prebend maxillofacial reconstruction plates is associated with decreased operating room time and costs. Using an on-site 3D printer requires minor start-up and use costs and results in a significant reduction in operating room time, which remains one of the most expensive aspects of facial trauma care.

Are Emergency Medicine Physicians Able to Determine the Need for Computed Tomography and Specialist Consultation in Odontogenic Maxillofacial Infections?

PURPOSE: Pain and swelling from a necrotic tooth is a common complaint in emergency departments. These patients impose substantial burdens on hospital budgets and provider time. The initial triage of odontogenic infections can be difficult without advanced knowledge and training in head and neck anatomy and odontogenic disease pathogenesis. The purpose of this study was to determine the frequency with which emergency medicine physicians correctly determine the need for computed tomography (CT) and specialist consultation in patients with odontogenic infections. MATERIALS AND METHODS: A retrospective case series was designed. Patients older than 18 years with an odontogenic infection presenting to the emergency department from August 1, 2012 to April 30, 2015 were eligible for inclusion in the study. Demographic, clinical, laboratory, and treatment data were recorded, with special attention paid to the hospital service consulted and imaging ordered. The location of the abscess and the clinical presentation of the patient were used to determine the necessity for the imaging and consultation. Descriptive statistics were used to analyze the data. RESULTS: Seventy-two patients met the inclusion criteria (52.9% women; mean age, 40.0 yr). The decision to order CT was made by emergency medicine physicians for 61.7% of patients with infections that did not require CT. Likewise, oral and maxillofacial surgery was consulted for 77.8% of patients with infections that did not require a specialist consultation. CONCLUSION: In this study, emergency medicine physicians misinterpreted the clinical needs of a large percentage of patients with odontogenic infections. Better education, interdepartmental collaboration, and conducting and disseminating peer-reviewed research are several ways to increase efficiency of care in patients with odontogenic infections.