Epidemiology, etiopathogenesis, and management of MRONJ: a European multicenter study.

INTRODUCTION: The purpose of this European multicenter study was to describe the general characteristics and risk factors of MRONJ lesions as well as their clinical diagnosis and management at different European Oral and Maxillofacial Surgery centers, in order to minimize selections biases and provide information about the epidemiology, etiopathogenesis, and the current trends in the treatment of MRONJ across Europe. MATERIALS AND METHODS: The following data were registered for each patient: gender; age at MRONJ diagnosis; past medical history; indication for antiresorptive or antiangiogenic therapy; type of antiresorptive medication; local risk factor for MRONJ; MRONJ Stage; anatomic location and symptoms; treatment; surgical complications; recurrence. RESULTS: A total of 537 patients (375 females, 162 males) with MRONJ were included. Statistically significant associations were found between patients with metastatic bone disease and recurrences (P < 0.0005) and between advanced MRONJ stages (stages 2 and 3) and recurrences (P < 0.005). Statistically significant associations were also found between male gender and recurrences (P < 0.05), and between MRONJ maxillary sites and recurrences (P < 0.0000005). CONCLUSIONS: A longer mean duration of antiresorptive medications before MRONJ onset was observed in patients affected by osteoporosis, whereas a shorter mean duration was observed in all metastatic bone cancer patients, and in particular in those affected by prostate cancer with bone metastases or multiple myeloma. Surgery plays an important role for the management of MRONJ lesions.

Oral and oropharyngeal malignant minor salivary gland tumors: A retrospective study.

INTRODUCTION: Tumors of minor salivary gland origin are uncommon lesions, representing 2-3 % of all malignant neoplasms of the upper aerodigestive tract and 9-23 % of all salivary gland tumors. The aim of this study is to report the demographic features, sites, histological types and the management and outcomes of oral and oropharyngeal minor salivary gland tumors diagnosed and treated in a University Hospital with a multidisciplinary head and neck team. MATERIALS AND METHODS: A single-center retrospective observational study was conducted in a cohort of patients who received diagnosis of minor salivary gland carcinoma of oropharynx and oral cavity between July 30th 2000 and 30th September 2021. The following data of the included patients were collected: age, gender, smoke history, alcohol consumption, past medical history, comorbidities, anatomic location of the tumor, histopathology, staging, management, and outcomes. RESULTS: A total of 30 cases (16 females, 14 males) of oral and oropharyngeal minor salivary gland tumors were reviewed. The most frequent histotype was polymorphous adenocarcinoma (12 patients). The majority of patients presented with low stage at diagnosis, with 66,66 % of the population classified as stage I or II at diagnosis. On the whole, 29 patients out of 30 benefitted from a surgical approach as first treatment. In 11 patients, adjuvant radiotherapy was performed and in 6 cases it was associated with chemotherapy. Brachytherapy with different timing was performed in 5 cases. The recurrence rate was 26.66 %. Overall disease specific survival at five and ten years was found to be approximately 81 % and 33 % respectively. CONCLUSIONS: Surgery is still considered to be the gold standard of the treatment of minor salivary gland tumors. Radiation therapy, in spite of not being considered as a curative primary treatment for salivary malignancies, is extensively used as an adjuvant treatment.

Breast Ductal Infiltrative Adenocarcinoma Metastasis to the Mandible.

Metastatic lesions to the jaws are rare. The oral sites to which metastasis most commonly occur are the jaws, the gingiva, and the tongue. Lower jaw is a more frequent site of metastasis compared to the upper jaw with posterior areas (ramus, body) that are more prone to the deposition of cancerous cells due to presence of hematopoietic bone marrow, subdivision of local blood vessels and reduced velocity of blood flow. In fact, the formation of secondary foci of tumor colonization occurs by hematogenous dissemination of tumor emboli, that accumulate in regions with larger amounts of bone marrow and low circulatory velocity. In females, commonly seen metastatic lesions arise from primary neoplasms in breasts, colon, genitals and thyroid glands, whereas in males arise from lungs, prostate and colon region. Patients with metastatic jaw disease may be asymptomatic or may show various clinical signs and symptoms that include pain, swelling, paresthesia, foul smell, tooth mobility, exophytic growths of the soft tissues, reduced mouth opening and, infrequently, pathological fractures. In particular, metastasis in breast cancer is commonly seen in the lungs, liver, bones, pleura, brain, and kidneys, whereas breast cancer metastasis to the oral cavity is not common and is seen in only around 1% of the cases. Breast cancer can also be latent where the metastases appear years after treatment of the primary tumor. The presence of metastasis is highly important in determining the patient's prognosis and mode of treatment. The aim of the present article is to present and discuss the diagnosis of a breast cancer metastasis in the mandibular angle.

Patient's perception of recovery following surgical removal of mandibular third molars. A prospective european multi-center study.

This study evaluated patient's perception of recovery following surgical removal of mandibular third molars (SRM3s) including analyze of potential risk factors associated with impaired convalescent. Patient related parameters combined with preoperative questionnaires including Modified Dental Anxiety Scale, Oral Health Impact Profile-14, and Decayed, Missing, Filled Teeth index were correlated with questionnaires assessing pain, swelling, trismus, sick leave, social and working isolation, physical appearance, eating and speaking ability, diet variations, sleep impairment, impaired sensation of the lip, chin, and tongue, one month following SRM3s. Totally, 412 patients (223 females, 189 males) with mean age of 29.4 years were included. Treatment satisfaction and willingness to undergo similar surgery were reported by 92% and 95%, although 21% reported that the surgery and postoperative period had been worse than expected. Mean days with pain, sick leave, and swelling were 3.6, 2.1, and 3.6, respectively. Preoperative symptoms, dental anxiety level, and prolonged surgical time were associated with increased pain and swelling (P < 0.05). Pell and Gregory classification (I-IIIC) were associated with impaired sensation of the lower lip and chin (P < 0.05). Consequently, results from this study improve the surgeon's ability to predict parameters that predisposed to impaired recovery and neurosensory disturbances following SRM3s.

The use of Anatomage table for metastases to the oral region.

INTRODUCTION: The Anatomage Table is a modern device characterized by virtual reality functionality that may be used to enhance the teaching of human anatomy to medical and allied health students. The purpose of the present study was to use the virtual dissection table (3D Anatomage) as an additional tool for education and information in cases of metastases to the oral region. MATERIALS AND METHODS: The hospital database of Vercelli Hospital, Vercelli, Italy, was searched for metastases to the oral region. DICOM data of Computed tomography scans were retrieved and uploaded in the Anatomage Table device. The workstation was used to obtain images of the body surface, "dissection cuts," or "vascular reconstructions," modifying the filters. RESULTS: The reconstructed images of three cases of metastases to the oral region from pulmonary adenocarcinoma, pulmonary sarcomatoid carcinoma, and breast ductal infiltrative adenocarcinoma were produced and presented. Different filters were used. DISCUSSION: The use of Anatomage Table, a touch interactive anatomy virtual dissection table used in anatomy education, thanks to the application of different filters, may represent a promising resource both for patients and students.

The epidemiology and management of odontomas: a European multicenter study.

INTRODUCTION: Odontoma is the most commonly diagnosed odontogenic tumor of the oral cavity. The objective of the present study was to assess the demographic variables, patterns, diagnostic features, and management issues of odontomas treated at several European departments of maxillofacial and oral surgery. MATERIALS AND METHODS: This study was conducted at 8 European departments of oral surgery between January 1, 2004, and December 31, 2018. Only patients with odontomas were included. The following data were recorded for each patient: gender, age, comorbidities, site, size of odontomas, radiographic features, type of odontoma, treatment of odontomas, treatment of associated teeth, complications, and recurrence. RESULTS: A total of 127 patients (70 male and 57 female patients) with odontomas were included. The mean age was 22 years; 71 odontomas were found in the mandible, whereas 56 in the maxilla. In the mandible, the most frequently involved subsite was the parasymphysis, while in the maxilla, the most common subsite was the upper incisor region. The mean size of included odontomas was 15.3 mm. On the whole, 62 complex odontomas, 50 compound odontomas, and 15 mixed-type odontomas were observed. Complete excision of the odontomas was performed in 121 patients. In 24 patients, the extraction of deciduous teeth was performed, and in 43 patients, one or more permanent teeth were removed. Finally, in 9 patients, a partial excision of the odontoma was performed. Recurrence was observed in 4 cases out of 127 patients. CONCLUSIONS: Dental practitioners should be aware of the distinct clinical and radiographic features of odontoma in order to perform an appropriate and early diagnosis. Conventional radiography, such as panoramic radiograph, is often sufficient technique for a diagnosis after clinical suspicion or for an incidental diagnosis to prevent later complications, such as impaction or failure of eruption of teeth.

Quality of life following maxillofacial trauma in the elderly: a multicenter, prospective study.

BACKGROUND/AIMS: When facial trauma involves elderly patients, the possible presence of frailty and comorbidities in victims of trauma may worsen the posttraumatic symptoms and decrease quality of life. The aim of this multicenter study was to assess the quality of life following surgical or non-operative management of maxillofacial trauma in elderly patients. MATERIALS AND METHODS: This cohort study was based on the administration of validated self-administered questionnaires to all the geriatric patients (70 years or more) with facial fractures from the involved maxillofacial surgical units across Europe, since 1st January 2019 to 31st June 2019. The following questionnaires were administered: SF36 questionnaire; the VFQ-25 questionnaire; the Oral Health Impact Profile - 14 (OHIP14). Outcome variables were VFQ-25 and OHIP-14 results. RESULTS: A total of 37 patients (14 male and 23 female patients) met the inclusion criteria and were included in the study. Elderly patients had an improvement in almost all the categories examined by the SF-36 questionnaire 6 months after trauma, with the only exception of a worsening as for role limitations due to physical health. An improvement was observed in almost all the categories at SF-36 test. A worsening of scores of OHIP-14 for all the considered dimensions in the whole study population was observed too. CONCLUSIONS: Elderly patients following facial trauma experience significant emotional, social, and functional disturbances. We observed that emotional problems, energy/fatigue, social functioning, and generally social limitations played a great role in the decrease of QoL in elderly patients following maxillofacial trauma.

Imaging of odontogenic keratocysts: a pictorial review.

INTRODUCTION: The aim of the present article was to review and depict the main radiological features of odontogenic keratocysts (OKCs), thus helping the differential diagnoses from other odontogenic cysts and neoplasms. EVIDENCE ACQUISITION: A review of articles published between January 2000 and October 2020 using Medline and the MeSH Term "odontogenic keratocyst" in combination with the following terms "imaging," "radiology," "panoramic radiograph," and "computed tomography," was performed. EVIDENCE SYNTHESIS: Radiographically, OKCs are well-defined unilocular or multilocular radiolucencies bounded by corticated margins. Most lesions are unilocular; instead, multilocular OKCs represent about the 30% of cases, mainly involving the posterior mandible. When, particularly in large lesions, OKCs display a multilocular presentation with adjacent satellite cysts (daughter cysts) a "soap-bubble appearance" can be recognized. DISCUSSION: Panoramic radiograph and CT still play an important role in the diagnosis and treatment planning of OKCs. Unfortunately, it may not be easy to differentiate OKCs from other odontogenic lesions, especially when they are small and unilocular. CONCLUSIONS: Histopathological findings are still necessary to obtain a definitive diagnosis.

The epidemiology and management of odontogenic keratocysts (OKCs): A European multicenter study.

The objective of the present study was to assess the epidemiology including demographic variables, diagnostic features, and the management of odontogenic keratocyst (OKCs) at several European departments of maxillofacial and oral surgery. This study is based on a systematic computer-assisted database that allowed the recording of data from treated OKCs. The following data were recorded for each patient: gender, age, voluptuary habits, comorbidities, site, size, radiographic features, treatment of OKCs, length of hospital stay, complications, recurrence, management and complications of eventual recurrence. A total of 405 patients, 249 male and 156 female, with 415 OKCs (407 sporadic and 8 syndromic lesions) were included in the study: 320 lesions were found in the mandible, whereas 95 were found in the maxilla. In the mandible, the most frequently involved subsite was the angle, whereas in the maxilla it was the molar region. The most frequently performed treatment option was enucleation plus curettage/peripheral ostectomy in 204 OKCs (recurrence rate, 9%). Decompression without residual cystectomy (recurrence rate, 66%), marsupialization with residual enucleation with the use of Carnoy's solution (recurrence rate, 50%), decompression with residual cystectomy (recurrence rate, 43%), and simple enucleation (recurrence rate, 24%) were the treatment options with the highest recurrence rates. An appropriate management of odontogenic keratocysts should be individualized, taking into consideration clinical and radiological findings, as well as patients' age and comorbidities.

The use of mandibular advancement devices in adult patients affected by obstructive sleep apnea syndrome: our experience with Thornton Adjustable Positioner® splint.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is a sleep-related disorder resulting in apneic and hypopneic episodes during sleep. The purpose of this article was to present and discuss our experience with the Thornton Adjustable Positioner® (TAP) Splint (Scheu-Dental GmbH, Iserlohn, Germany; Orthosystem, Milan, Italy) in a consecutive series of patients affected by OSAS. METHODS: The data of all patients affected by OSAS and with indication to oral appliance (OA) treatment at the Department of Dentistry of the Hospital of Vercelli between January 1, 2019, and December 31, 2019, were collected. The following data were recorded for each patient: gender, age, smoke and/or alcohol assumption, BMI, comorbidities and current pharmacological therapy, initial AHI, OSAS category, eventual performed OSAS treatment options before OA treatment, indication to OA treatment, final AHI following OA treatment, complications and side effects. RESULTS: A total of 18 subjects (11 men, 7 women) with a mean age of 58.8 years were enrolled in this study with a mean AHI of 27.9 (range 5.884). Average BMI was 29. OA treatment reduced AHI in all patients (mean post treatment AHI: 5; range: 3.1-8). All patients were satisfied with the subjective improvement of OSAS symptoms. CONCLUSIONS: Our results confirm the usefulness of a specific type of mandibular advancement device that can be considered as a valuable therapeutic modality in OSAS patients. Side effects are limited, and they usually do not decrease the compliance of patients.

The epidemiology and management of ameloblastomas: A European multicenter study.

The present study aimed at assessing the epidemiology including demographic variables, diagnostic features, and management of ameloblastomas at several European departments of maxillofacial and oral surgery. The following data were recorded for each patient: gender, age, voluptuary habits, comorbidities, site, size, radiographic features, type, histopathological features, kind of treatment, length of hospital stay, complications, recurrence, management and complications of the recurrence. A total of 244 patients, 134 males and 110 females with ameloblastomas were included in the study. Mean age was 47.4 years. In all, 81% of lesions were found in the mandible, whereas 19% were found in the maxilla. Mean size of included ameloblastomas was 38.9 mm. The most frequently performed treatment option was enucleation plus curettage/peripheral ostectomy in 94 ameloblastomas, followed by segmental resection (60 patients), simple enucleation (46 patients), and marginal resection (40 patients). A recurrence (with a mean follow up of 5 years) was observed in 47 cases out of 244 ameloblastomas (19.3%). Segmental resection was associated with a low risk of recurrence (p = 0003), whereas enucleation plus curettage/peripheral ostectomy was associated with a high risk of recurrence (p = 0002). A multilocular radiographic appearance was associated with a high risk of recurrence (p < .05), as well as the benign solid/multicystic histologic type (p < .05). Within the limitations of the study it seems that the management of ameloblastomas will probably remain controversial even in the future. Balancing low surgical morbidity with a low recurrence rate is a difficult aim to reach.

Simple Parameters from Complete Blood Count Predict In-Hospital Mortality in COVID-19.

INTRODUCTION: The clinical course of Coronavirus Disease 2019 (COVID-19) is highly heterogenous, ranging from asymptomatic to fatal forms. The identification of clinical and laboratory predictors of poor prognosis may assist clinicians in monitoring strategies and therapeutic decisions. MATERIALS AND METHODS: In this study, we retrospectively assessed the prognostic value of a simple tool, the complete blood count, on a cohort of 664 patients (F 260; 39%, median age 70 (56-81) years) hospitalized for COVID-19 in Northern Italy. We collected demographic data along with complete blood cell count; moreover, the outcome of the hospital in-stay was recorded. RESULTS: At data cut-off, 221/664 patients (33.3%) had died and 453/664 (66.7%) had been discharged. Red cell distribution width (RDW) (χ 2 10.4; p < 0.001), neutrophil-to-lymphocyte (NL) ratio (χ 2 7.6; p = 0.006), and platelet count (χ 2 5.39; p = 0.02), along with age (χ 2 87.6; p < 0.001) and gender (χ 2 17.3; p < 0.001), accurately predicted in-hospital mortality. Hemoglobin levels were not associated with mortality. We also identified the best cut-off for mortality prediction: a NL ratio > 4.68 was characterized by an odds ratio for in-hospital mortality (OR) = 3.40 (2.40-4.82), while the OR for a RDW > 13.7% was 4.09 (2.87-5.83); a platelet count > 166,000/µL was, conversely, protective (OR: 0.45 (0.32-0.63)). CONCLUSION: Our findings arise the opportunity of stratifying COVID-19 severity according to simple lab parameters, which may drive clinical decisions about monitoring and treatment.

Fatality rate and predictors of mortality in an Italian cohort of hospitalized COVID-19 patients.

Clinical features and natural history of coronavirus disease 2019 (COVID-19) differ widely among different countries and during different phases of the pandemia. Here, we aimed to evaluate the case fatality rate (CFR) and to identify predictors of mortality in a cohort of COVID-19 patients admitted to three hospitals of Northern Italy between March 1 and April 28, 2020. All these patients had a confirmed diagnosis of SARS-CoV-2 infection by molecular methods. During the study period 504/1697 patients died; thus, overall CFR was 29.7%. We looked for predictors of mortality in a subgroup of 486 patients (239 males, 59%; median age 71 years) for whom sufficient clinical data were available at data cut-off. Among the demographic and clinical variables considered, age, a diagnosis of cancer, obesity and current smoking independently predicted mortality. When laboratory data were added to the model in a further subgroup of patients, age, the diagnosis of cancer, and the baseline PaO2/FiO2 ratio were identified as independent predictors of mortality. In conclusion, the CFR of hospitalized patients in Northern Italy during the ascending phase of the COVID-19 pandemic approached 30%. The identification of mortality predictors might contribute to better stratification of individual patient risk.

Optical Coherence Tomography Findings Following Orbital Fractures.

INTRODUCTION: A closed globe trauma is often associated with orbital wall fractures. In addition to diplopia, further eye disturbances can be observed. The aim of this preliminary prospective study was to investigate the optical coherence tomography (OCT) findings in patients that presented with orbital fractures in association with diplopia but without decreased visual acuity or further ocular symptoms. METHODS: Only patients who were admitted and surgically treated for orbital wall fractures and that presented diplopia were included in this study. Patients with post traumatic ocular symptoms were excluded. All the patients that were diagnosed with an orbital fracture underwent an ophthalmological assessment, including best-corrected visual acuity (BCVA), examination of fundus oculi, Hess Scheme, OCT, and OCT angiography. RESULTS: Five patients met the inclusion criteria and were enrolled. Hess Scheme examinations confirmed the presence of diplopia in all the included patients. The examination of fundus oculi did not reveal any pathology in 4 patients, whereas in a patient a commotio retinae (Berlin's Edema) was diagnosed in the infero-papillary field. Following OCT assessment, a pachycoroid was observed in 4 patients. CONCLUSIONS: A thorough ophthalmological assessment in patients that have suffered from orbital fractures is fundamental. In particular, OCT examinations seem to provide more insight into the detection and monitoring of choroidal changes after ocular trauma without visible macular changes.

The various meanings and imperfections of words.

In this reply to a letter, the Authors discuss the raised points regarding the nomenclature and management of Lymphatic Malformations / Lymphangiomas.

The use of optical scanner for the fabrication of maxillary obturator prostheses.

INTRODUCTION: Maxillectomy following tumors or, more rarely, traumatic injuries may result in maxillary defects that may determine physical dysfunctions and functional impairment of speech and swallowing. The aim of our study was to present our experience in the management of post-maxillectomy patients by the use of obturator prostheses that were obtained by 3D digital casts via an intraoral scanner. METHODS: Patients with maxillary defects following maxillary and/or palatal resection or maxillary traumatic avulsion were selected for this clinical study between 2015 and 2018. Five to 6 months after surgery, a definitive obturator prosthesis was fabricated thanks to an intraoral scanner. The following parameters of clinical outcome were considered: the absence of fluid leakage, the recovery of phonation, the recovery of swallowing, and personal satisfaction. RESULTS: Twenty-eight patients (20 males, 8 females) fulfilled the inclusion criteria and were included in the study. Most patients had a maxillary and/or palatal defect because of a malignant tumor. On the whole, 93% of patients reported a complete absence of fluid leakage between maxillary sinuses or nasal fossa and oral cavity; most patients reported a good or complete recovery of phonation and swallowing. CONCLUSIONS: Digital technology for the fabrication of maxillary obturator prosthesis may be effective and useful. The reduced laboratory working time, the avoidance of the risk of aspiration of impression materials, and the overcome of the difficulties associated with whole tissue undercut impression are just some of the most important advantages that have been encountered thanks to this promising technology.

A single-center experience in the management of head and neck lymphangiomas.

INTRODUCTION: Lymphangiomas are relatively uncommon head and neck region lymphatic malformations. Although surgery can be still considered the mainstay of treatment, sclerotherapy by OK-432 is becoming a widespread treatment option. The aim of this article is to present and discuss the management and outcomes of a series of cases of lymphangiomas. METHODS: All patients with lymphangiomas who were treated from 2010 to 2018 were reviewed. The following data were recorded: age, gender, subtype, staging, type of treatment, outcome, and recurrence. RESULTS: Fifteen patients (9 females, 6 males) were included with 2 microcystic and 13 macrocystic lymphangiomas. Six patients underwent surgery with excision (5 with a complete success, one with a fair success), whereas the remaining 9 subjects underwent sclerotherapy by OK-432 (6 with a complete success, 3 with a fair success). No postoperative complications were observed. CONCLUSIONS: All modes of treatment are important in properly selected patients affected by lymphangiomas. OK-432 therapy is a safe and effective option in the treatment of head and neck lymphangiomas.

The potentialities of the Anatomage Table for head and neck pathology: medical education and informed consent.

INTRODUCTION: The understanding of anatomy of head and neck region and of the relative pathological conditions may be challenging for most medical students. Furthermore, patients may encounter great difficulties to understand their pathology, the proposed surgical technique, as well as the anatomy of this body district. The purpose of the present study was to present and discuss the use of the Anatomage Table for the assessment of several benign and malignant conditions of head and neck district. MATERIALS AND METHODS: The hospital database of Novara University Hospital, Novara, Italy, was searched for odontogenic keratocysts, thyroglossal duct cysts, and oral squamous cell carcinomas. A case for each pathology was randomly chosen, and preoperative computed tomography (CT) scans (in DICOM files) were retrieved. The DICOM data of preoperative CT examinations were uploaded in the Anatomage Table device, and an immediate 3-D reconstruction image was obtained from the Anatomage Table. Then, a workstation was used to obtain images of the body surface, "dissection cuts," or "vascular reconstructions," by the variations of the filters. RESULTS: The "dissection," "vascular," and "bony" images of three cases of odontogenic keratocyst, thyroglossal duct cyst, and mandibular oral squamous cell carcinoma were produced and presented. DISCUSSION: The examination of the different slices and the application of different filters represent a promising tool both for the education of students/residents and for an improved informed consent by the patients.

The relationship between the status and position of third molars and the presence of mandibular angle and condylar fractures.

INTRODUCTION: The aim of this study was to assess the relationship between the status and position of third molars, and the presence of mandibular angle and/or condylar fractures, in a group of patients treated for mandibular fractures, thus hoping to contribute to the knowledge of potential predictors of these fractures. METHODS: A retrospective study was designated to include all the patients who were diagnosed and treated with open reduction and internal fixation for isolated mandibular angle fractures or isolated mandibular condylar fractures between 1st of January 2012 and 31st of December 2018. The following data were collected for each included patient: gender, age, etiology, site and side of the fracture, and presence and eruption state of third molars in the fracture side. RESULTS: Seventy patients were diagnosed with a condylar fracture, 48 with an angle fracture. No statistically significant difference was observed as for etiology and gender distribution between angle fracture and condyle fracture patients (p > 0.05). Angle fractures were statistically associated with the presence of third molars, whereas condylar fractures with the absence of third molars (p < 0.000005). The presence of completely erupted 3Ms was associated with condylar fractures (p < 0.05), and partially impacted 3Ms were associated with angle fractures (p < 0.0005). CONCLUSIONS: Mandibular angle fractures and third molar presence are associated in patients who present with mandibular fractures, especially if the third molar is incompletely erupted. This information should be kept in consideration as for the diagnosis and management of patients with mandibular fractures.