Third Molar Extractions in Patients With Developmental Disabilities.

BACKGROUND: Patients with developmental disabilities may exhibit behavioral problems or be unable to maintain proper hygiene, potentially placing them at greater risk for infection following the extraction of third molars. PURPOSE: The purpose of this study was to estimate and compare the risk for surgical site infection after third molar removal between patients with and without developmental disabilities. STUDY DESIGN, SETTING, SAMPLE: This was a retrospective cohort study of patients who underwent extraction of all four-third molars at Boston Children's Hospital from August 1, 2021, to July 31, 2023. Patients were excluded if all four-third molars were not present or if all four-third molars were not extracted during one visit. PREDICTOR VARIABLE: The primary predictor variable was developmental disability status. Subjects were grouped by developmental disability, coded as present or absent. MAIN OUTCOME VARIABLE: The primary outcome variable was diagnosis of a postoperative surgical site infection. Secondary outcomes included time to follow-up and infection treatment. COVARIATES: Covariates included age, sex, race, ethnicity, procedure setting, anesthesia type, and impaction status. ANALYSES: Independent Samples T-tests, χ2 tests, and Fisher's Exact tests were used for analysis. RESULTS: A total of 1,896 subjects were evaluated. There were 236 subjects in the developmental disability group (72.5% male [n = 171] mean age of 19.3 ± 2.7 years) and 1,660 in the nondevelopmental disability group (53.4% female [n = 887] mean age of 19.0 ± 2.3 years). Subjects in the developmental disability group more frequently underwent their extractions in the operating room under general anesthesia (57.6% [n = 136] P < .001). The overall postoperative infection rate was 2.7% (n = 52). There was no statistically significant difference in the rate of infection between the developmental disability group (0.8% [n = 2]) and the nondevelopmental disability group (3.0% [n = 50]) (P = .057). There was no significant difference in time to follow-up between subjects who were and were not diagnosed with an infection (6.26 ± 9.39 weeks vs 4.69 ± 10.95 weeks, P = .434) or for subjects in the developmental disability and nondevelopmental disability group who had an infection (2.64 ± 0.30 weeks vs 6.43 ± 9.76 weeks, P = .588). CONCLUSION AND RELEVANCE: Patients with a developmental disability do not exhibit higher rates of postoperative infections following third molar extractions when compared to patients without developmental disabilities.

Cortical Block Grafting Successfully Augments Alveolar Cleft Sites for Dental Implant Placement.

BACKGROUND: Supplemental bone grafting is regularly required before dental implant placement in patients with cleft lip and palate (CLP). PURPOSE: The study purpose was to measure and compare implant osseointegration and changes in graft dimensions following lateral incisor onlay cortical bone grafting in CLP and non-CLP patients. STUDY DESIGN, SETTING, SAMPLE: Retrospective cohort study composed of patients who presented to Boston Children's Hospital and underwent autogenous onlay cortical block bone grafting at lateral incisor sites from 2015 through 2023. Patients were excluded if the cone beam computed tomography (CBCT) quality was insufficient for accurate measurements. PREDICTOR VARIABLE: The predictor variable was CLP status coded as CLP or non-CLP. MAIN OUTCOME VARIABLE: The primary outcome variable was successful implant osseointegration confirmed by a torque of 35 N/cm or more after 3 months of implant healing. Secondary outcomes were change in bone width between preoperative and postoperative CBCT scans at lateral incisor sites and the need for additional bone augmentation prior to or during implant placement. COVARIATES: Covariates were age, sex, cleft location, and time from bone graft to postoperative CBCT and implant placement. ANALYSES: Data analyses were performed using t-tests, Fisher's exact tests, Mann-Whitney U tests, and Pearson's correlation. P < .05 was considered statistically significant. RESULTS: A total of 22 subjects (16 with CLP) were evaluated. The mean age at the time of graft was 19.3 ± 2.4 years with 52.6% males. Implants were osseointegrated at 20 of 22 lateral incisor sites (1 CLP failure, 1 non-CLP failure). There was significant change in bone width after grafting for patients with CLP (P < .001). Patients with CLP experienced a 3.32 (± 1.80) mm and 2.99 (± 1.61) mm increase in bone width at 2 different levels. Patients with CLP achieved greater boney changes near the alveolar crest than noncleft patients (P = .008) but the change was not significantly different more apically (P = .86). One subject with CLP required additional grafting during implant placement. CONCLUSION AND RELEVANCE: Cortical block onlay bone grafting is a predictable technique to augment lateral incisor sites in patients with CLP for placement of a dental implant.

An Enhanced Recovery After Surgery (ERAS) Protocol for Orthognathic Surgery Reduces Rates of Postoperative Nausea.

For many surgical procedures, enhanced recovery after surgery (ERAS) protocols have improved patient outcomes, particularly postoperative nausea and vomiting. The purpose of this study was to evaluate postoperative nausea following orthognathic surgery after the implementation of an ERAS protocol. This retrospective cohort study included patients between 12 and 35 years old who underwent orthognathic surgery at Boston Children's Hospital from April 2018 to December 2022. Patients with syndromes or a hospital stay greater than 48 hours were excluded from the study. The primary predictor was enrollment in our institutional ERAS protocol. The main outcome variable was postoperative nausea. Intraoperative and postoperative covariates were compared between groups using unpaired t tests and chi squared analysis. Univariate and multivariate regression models with 95% confidence intervals were performed to identify predictors for nausea. A P value<0.05 was considered significant. There were 128 patients (68 non-ERAS, 60 ERAS) included in this study (51.6% female, mean age 19.02±3.25 years). The ERAS group received less intraoperative fluid (937.0±462.3 versus 1583.6±847.6 mL, P ≤0.001) and experienced less postoperative nausea (38.3% versus 63.2%, P =0.005). Enhanced recovery after surgery status ( P =0.005) was a predictor for less postoperative nausea, whereas bilateral sagittal split osteotomy ( P =0.045) and length of stay ( P =0.007) were positive predictors for postoperative nausea in multivariate logistic regression analysis. Implementing an ERAS protocol for orthognathic surgery reduces postoperative nausea. Level of Evidence: Level III-therapeutic.

What factors influence mucocele recurrence?

OBJECTIVE: The purpose of this study was to identify whether age is associated with mucocele recurrence after excision. STUDY DESIGN: This retrospective cohort study consisted of 492 patients who underwent oral mucocele excision at Boston Children's Hospital from 2010 to 2022. Fisher's exact tests were used to assess the association between age and mucocele recurrence. An adjusted logistic regression model was run to evaluate the effect of age on mucocele recurrence while controlling for confounders. A P value < .05 was considered significant. RESULTS: Mucocele recurrence was observed in 24 cases (4.9%). There was a significant association between age and mucocele recurrence (2.2% for <7 years vs. 2.9% for 7 to <13 years vs. 9.2% for 13 to <18 years vs. 8.9% for >18 years; P = .005). Sex; history of behavioral disorders; mucocele size, duration, and location; suture technique; and type of anesthesia were not significantly associated with recurrence (P > .135). An adjusted logistic regression model verified a significant association between age and mucocele recurrence (odds ratio, 1.053; 95% confidence interval, 1.019-1.088; P = .035). CONCLUSIONS: Mucocele recurrence occurs infrequently in patients younger than 7 years and is most prevalent in the teenage to young adult patient population. For every year increase in age, the odds of mucocele recurrence increase by 5.3%.

Patient-specific Le Fort I Osteotomy Plates are More Stable than Stock Plates in Patients with Cleft Lip and Palate.

BACKGROUND: There is evidence that patient-specific plate fixation for Le Fort I osteotomies (LFI) is more stable than traditional plates. The purpose of this study was to evaluate stability of LFI in patients with cleft lip and palate (CLP) and determine stability differences between patient-specific and stock plates. METHODS: Consecutive patients with CLP who underwent isolated LFI by one surgeon (BLP) between 2016 and 2021 were included. The predictor variable was type of plate used for fixation (patient-specific or stock). The outcome variable was magnitude of relapse in the vertical (Nasion-A point) and horizontal planes (Basion-A point) at one year post LFI using 3-dimensional cone beam computed tomography. Statistical analysis included Independent Samples T-test, Mann-Whitney U, Fisher's exact and Chi-square tests. P<0.05 was significant. RESULTS: The sample included 63 subjects; 23 (36.5%) in the patient-specific group and 40 (63.5%) in the stock group. Groups were comparable by sex, race, age at operation, cleft type, presence of pharyngeal flap and magnitude of horizontal movement (P>0.136, all). Subjects who underwent patient-specific plate fixation were less likely to have ≥1mm change at one year in the horizontal (4.3% vs. 50.0%, p<.001) and vertical planes (4.3% vs. 65.0%, P<.001) compared to stock plates. For patients who had >10mm horizontal advancement, the patient-specific plates had significantly less relapse (patient-specific 0.105mm ± 0.317mm vs. stock 1.888mm ± 1.125mm vs, P=.003). CONCLUSIONS: Patient-specific plate fixation of LFI is more stable and demonstrates less relapse after one year than stock plates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.