Should Degree of Third Molar Eruption Influence Operative Management of Mandibular Angle Fractures? A Systematic Review.

Study Design: Systematic review. Objective: There is a growing trend toward evidence-based management of third molars in the fracture line of mandibular angle fractures (MAFs). This study aimed to differentiate MAF fixation complications by degree of third molar eruption and by extraction strategy in patients undergoing Champy fixation. Methods: PubMed, EMBASE, OVID, SCOPUS, the Cochrane Library, and clinicaltrials.gov were queried through May 2020 for English-language publications for MAFs with third molar involvement for this systematic review. Bias was assessed using author-defined criteria. Relative risk (RR) of post-operative complications associated with extracted unerupted and retained partially erupted third molars (Group I) was calculated against controls of retained unerupted and extracted partially erupted third molars (Group II). Results: Ten studies reported complications by eruption or extraction; however, only one study stratified complications by both eruption and extraction to meet inclusion criteria. The risk of bias was medium as only cases meeting defined follow-up were included. 73 cases (N) were included: 34 qualified for Group I and 39 for Group II. Quantitative synthesis of individual case data demonstrated significantly higher complication rate in Group I compared to Group II (23.5% vs 5.1%) (RR 4.6, 95% CI 1.04-20.1). No significant differences were observed between groups for infectious complications, mechanical complications, nonunion, or dehiscence. Reoperation was required significantly more often for Group I (P = .043). Conclusions: For MAFs involving the third molar, concomitant extraction of unerupted as well as retention of partially erupted third molars increases risk of complications with Champy fixation technique. For these patients, alternative strategies for fixation should be considered.

Orbital Index: A Novel Comprehensive Quantitative Tool for Prediction of Delayed Enophthalmos in Orbital Floor Fracture Management.

SUMMARY: Early identification of surgical indication is critical to optimizing outcomes in orbital floor fracture management. However, identifying those at risk for delayed enophthalmos and requiring subsequent repair has remained a challenge. This study aimed to validate the Orbital Index, a prediction tool using computed tomography to stratify risk for delayed enophthalmos and establish a threshold for repair. The Orbital Index stratifies fractures by size, location, and inferior rectus rounding (a surrogate for fascioligamentous sling disruption) on a scale 0 to 6. A 22-year (1998 to 2020) multi-institution analysis of unilateral isolated orbital floor fractures was performed. Index scores were assigned to each scan, unoperated patients invited for blinded Hertel exophthalmometry assessment, and enophthalmos measurements correlated with Index scores. Interobserver scoring reproducibility was assessed with weighted Cohen kappa. Preintervention and postintervention Likert scale surveys were administered to determine whether this tool improved understanding and communication. The Orbital Index demonstrated high fidelity and interobserver reproducibility and identified a score of four or greater as a surgical threshold. Of 1769 computed tomography scans, 395 met criteria and were included for analysis. Eighty of 395 were managed operatively (operative rate, 20.3 percent). Of 315 patients managed nonoperatively, 41 (13.0 percent) agreed to follow-up evaluation and 28 (68.3 percent) were found to have enophthalmos. Unoperated patients with an Orbital Index score of 4 or higher were more likely to have enophthalmos than those with a score of 3 or less ( p = 0.001). The mean weighted Cohen kappa was 0.73, corroborating reproducibility. Communication ( p = 0.0003) and ability to correctly identify surgical need ( p = 0.01) were improved with use of this tool. The Orbital Index is a reproducible tool to stratify risk for enophthalmos in orbital floor fracture management.

An age-related algorithm for management of micro-orbitism from anophthalmia: a systematic review with supplemental case reports.

Management of pediatric anophthalmia and resultant micro-orbitism is challenging. The efficacy and safety of treatment methods vary with age as bony changes grow recalcitrant to implants in those at skeletal maturity and osteotomies become technically challenging following frontal sinus pneumatization. This study aims to review methods for managing micro-orbitism and develop an age-based treatment approach. A systematic literature review was conducted. Data were screened and extracted by two investigators and relevant English-language primary-literature was analyzed. Information on sample-size, number of orbits, intervention, age, complications, and prosthetic retention was obtained. Representative case reports are presented, in addition. Nineteen studies met inclusion: 294 orbits in 266 patients were treated. Two studies reported distraction-osteogenesis. Two studies utilized bone grafting. Osteotomies were performed in 41 patients from three studies. Use of solid implants was detailed in two studies. Three studies described osmotic implant. Four studies described inflatable implants. Other techniques were described by three of the included studies, two of which utilized dermis-fat grafting. All but one study were observational case reports or case series. Across all studies regardless of surgical technique, risk of bias and heterogeneity was high due to attrition bias and selective outcomes-reporting. Selection of therapy should be tailored to skeletal-age to optimize outcomes; those 0-4 yrs are managed with dermis-fat grafts, 5-7 yrs managed with implants, and 8+ yrs managed with osteotomies. For those 8+ yrs with aerated frontal sinuses or insufficient bone stock, we propose onlay camouflage prosthetics which improve projection, increase orbital volume, and avoid risk for frontal sinus injury.

Orthoptic Vision Therapy: Establishing a Protocol for Management of Diplopia Following Orbital Fracture Repair.

INTRODUCTION: Persistent diplopia following orbital fracture is a well-recognized problem. While observation is the standard-of-care, symptoms may be protracted. Orthoptic vision therapy is a form of ocular physical therapy that achieves functional rehabilitation through targeted exercises. This study presents a protocol for post-traumatic orthoptics and describes preliminary results. MATERIALS AND METHODS: Protocols for home-therapy/office-assessment were developed using commercial software and exercises targeting motility and fusion. Office-assessment also included validated questionnaire chronicling symptomatology. Healthy-volunteers (n = 10) trailed the protocol three times (n = 30) and normative data was compiled. Comparative measurements were made in chronic (>1year; n = 8) and acute (<2 weeks; n = 4) fracture cohorts. Time-of-therapy was recorded, monetary cost-analysis performed, and side-effects assessed. RESULTS: Severe/moderate motility limitation was found in 3 of 4 acute fracture patients but not in chronic or healthy cohorts. The acute cohort had worse fusion when comparing convergence (mean break/recovery of 8.0/6.5 prism diopters (pd) versus 31.87/21.23pd; P = 0.001/0.015) and divergence (3.00/1.50pd versus 18.37/12.83pd; P = 0.000/0.001) to the healthy cohort. Those with chronic fracture had lower convergence (15.71/5.00pd; P = 0.01/0.001) and divergence (12.29/4.71pd; P = 0.04/0.002) when compared with healthy subjects, but better function than acute patients. Acute fracture patients reported greater symptomatology than chronic (mean score 18.8 versus 4.6; P = 0.003) or healthy (5.0; P = 0.02) groups, but there was no difference between chronic and healthy groups (P = 0.87). Assessment took <10 minutes. Per patient software cost was <$70. Mild eyestrain related to therapy was self-resolving in all cases. CONCLUSIONS: Orthoptic therapy may improve fusion and motility following orbital fracture. This protocol serves as basis for prospective work.

National Disparities in Insurance Coverage of Comprehensive Craniomaxillofacial Trauma Care.

Comprehensive craniomaxillofacial trauma care includes correcting functional deficits, addressing acquired deformities and appearance, and providing psychosocial support. The aim of this study was to characterize insurance coverage of surgical, medical, and psychosocial services indicated for longitudinal facial trauma care and highlight national discrepancies in policy. METHODS: A cross-sectional analysis of insurance coverage was performed for treatment of common functional, appearance, and psychosocial facial trauma sequelae. Policies were scored for coverage (3), case-by-case coverage (2), no mention (1), and exclusion (0). The sum of points determined coverage scores for functional sequelae, acquired-appearance sequelae, and psychosocial sequelae, the sum of which generated a Comprehensive Coverage Score. RESULTS: Medicaid earned lower comprehensive coverage scores and lower coverage scores for psychosocial sequelae than did private insurance (P = 0.02, P = 0.02). Medicaid CCSs were lowest in Oklahoma, Arkansas, and Missouri. Private insurance CCSs and psychosocial sequelae were highest in Colorado and Delaware, and lowest in Wisconsin. Coverage scores for functional sequelae and for acquired-appearance sequelae were similar for Medicaid and private policies. Medicaid coverage scores were higher in states that opted into Medicaid expansion (P = 0.04), states with Democrat governors (P = 0.02), states with mandated paid leave (P = 0.01), and states with >40% total population living >400% above federal poverty (P = 0.03). Medicaid comprehensive coverage scores and coverage scores for psychosocial sequelae were lower in southeastern states. Private insurance coverage scores for functional sequelae and for ASCSs were lower in the Midwest. CONCLUSIONS: Insurance disparities in comprehensive craniomaxillofacial care coverage exist, particularly for psychosocial services. The disparities correlate with current state-level geopolitics. There is a uniform need to address national and state-specific differences in coverage from both Medicaid and private insurance policies.

Standardized Schematics for Facial Trauma Planning: A Clinical Education Tool.

INTRODUCTION: Learning facial fracture management principles can be challenging for surgical trainees. Residents must assimilate nuances of fixation techniques, skeletal biomechanics, and hardware use while managing acute work-flow limitations. This study aims to design a standardized-schematic for teaching facial fracture management and evaluate its performance improving resident operative planning. METHODS: Printable schematics of the facial skeleton with soft-tissue overlay were developed. Instructions on depicting fracture pattern, incisions, plating sequence, loadbearing/sharing plates, locking/nonlocking screws, and mono/bicortical screws were given. Senior residents (n=5) evaluated computed tomography of 3 mandibular fractures and submitted 3 operative plans per case: first without guidance, then with written instruction, and finally using the schematic (n=45). Performance was graded on content and conceptual correctness. Data on time to completion was obtained. Likert-scale surveys assessing understanding, communication, and operative planning were given RESULTS:: Schematic use improved operative plan content and facilitated communication of resident operative schemes. Of 7 content domains spanning approach, plating strategy, and screw selection, a mean of 2.3, 3.7, and 6.5 were included with no guidance, written instruction, and schematic use respectively. Information on approach (P=0.001), plating type (P=0.02), screw location (P<0.000), screw depth (P=0.000), and screw locking status (P=0.000) were improved when comparing pre- and postintervention plans. Mean time to completion was 8 minutes and 54 seconds. All subjects "agreed" (n=2) or "strongly agreed" (n=3) that schematic use aided planning and communication. CONCLUSIONS: Simple, guided interventions can enhance surgical training by identifying knowledge gaps, improving visuospatial conceptualization, and facilitating targeted discussions with attendings.

Defining the Zygomaticosphenoidal Angle as a Guide to Anatomic Zygomaticomaxillary Complex Fracture Reduction.

BACKGROUND: Alignment of the zygomaticosphenoid suture is fundamental to reduction of zygomaticomaxillary complex fractures. To prevent a rotational deformity, the correct angle of the zygoma relative to the cranial base must be restored. Clinically, this can be a challenge, especially when there is comminution of the zygomaticosphenoid suture. Defining a zygomaticosphenoidal angle would provide a reference for use with stereotactic navigation to achieve anatomic reduction. METHODS: A single-center retrospective analysis of 100 patients was designed to determine normative zygomaticosphenoidal angle values. An angle subtended by the midline and a best-fit line through the zygomaticosphenoid suture on axial computed tomography was measured bilaterally in patients with isolated mandibular or nasal fractures. The mean of this measurement for 3 vertically adjacent cuts was calculated with position of central cut determined by the equator of the globe and trigone of the sphenoid. Multivariate regression was completed to identify changes in zygomaticosphenoidal angle with age, sex, and race. RESULTS: The mean zygomaticosphenoidal angle was 47° (range 39°-55°). 97% of angles were within 2 standard deviations (8°) of mean. Regression analysis demonstrated no significant change in angle with age (P = 0.74) or sex (P = 0.89). For each angle, the variation across the 3 sample cuts was ≤4.5°. Patients demonstrated high fidelity in zygomaticosphenoidal angle bilaterally with mean difference of 3°. CONCLUSION: The zygomaticosphenoidal angle is a useful reference, in conjunction with stereotactic navigation, for reduction of zygomaticomaxillary complex fractures. Contralaterally obtained patient-specific data may be used to guide unilateral repair. Normative values may serve as reference in bilateral injury.

Establishing a Protocol for Closed Treatment of Mandibular Condyle Fractures with Dynamic Elastic Therapy.

Treatment of mandibular condyle fractures is controversial. Open treatment achieves anatomic reduction with occlusal stability and faster functional recovery but risks facial nerve injury and jeopardizes joint capsule circulation which can lead to bone resorption. Traditional closed treatment avoids these issues but requires prolonged fixation and risks subsequent facial asymmetry, occlusal disturbance, and ankylosis. Rather than wires, closed treatment with elastics allows for customizable management of a healing fracture with ability to alter vector and degree of traction to restore vertical height and occlusion with less discomfort and decreased risk for ankylosis. In this protocol, unilateral condylar fractures were treated with class II elastics ipsilateral to injury and class I contralaterally. Class III elastics were used contralaterally if additional traction was required and Class II elastics were placed bilaterally for bilateral fractures. Patients were sequentially advanced from fixating to guiding to supportive elastics by titrating elastic vector to any dental midline incongruency or chin deviation. Six patients were treated with this protocol with six-month follow-up. Fracture patterns included displaced and dislocated fractures as well as intracapsular and extracapsular condylar fractures. All patients at completion of the protocol had objective centric occlusion with no subjective malocclusion, chin deviation, facial asymmetry, or temporomandibular joint pain. These early data demonstrate a safe and efficacious innovative protocol for closed treatment of mandibular condylar fractures with dynamic elastic therapy.