Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

Functional Anatomic Computer Engineered Surgery Protocol for the Management of Self-Inflicted Gunshot Wounds to the Maxillofacial Skeleton.

PURPOSE: Virtual surgical planning (VSP) is an indispensable aid in craniomaxillofacial reconstruction, yet no protocol is established in facial gunshot wounds. We review our experience with computer-aided reconstruction of self-inflicted facial gunshot wounds (SIGSW'S) and propose a protocol for the staged repair. METHODS: A retrospective case series enrolling patients with SIGSW's managed with the Functional Anatomic Computer Engineered Surgical protocol (FACES) was implemented. Subjects were evaluated at least one month postoperatively. Outcome variables were jaw position, facial projection, oro-nasal communication, lip competence, feeding tube and tracheostomy dependence, descriptive statistics were computed. The FACES protocol implemented during the initial hospitalization is as follows 1) damage control; 2) selective debridement; 3) VSP reconstruction back converted into navigation software 4) navigation assisted midfacial skeletal reconstruction; 5) computer aided oro-mandibular reconstruction with or without microvascular free flaps using custom cutting guides/hardware; 6) navigation assisted, computer aided palatomaxillary reconstruction with or without microvascular free flaps using cutting guides/hardware; 7) navigation assisted reconstruction of the internal orbit; 8) and confirmation of accurate reconstruction using intraoperative CT. RESULTS: The sample was composed of 10 patients, mean age of 43 years (range, 28 - 62 years, 70% M), 100% with SIGSW's to the submental/submandibular region. All had satisfactory facial projection (n=10), nine had satisfactory jaw position, were decannulated by one month's follow up and were feeding tube independent (90%). All traumatic oro-antral communications were closed (n=8, 7 surgical, 1 obturator), seven had adequate lip competence (70%). Complications included fibula malunion (n=1), plate exposure (n=2) infection (n=2), intracranial abscess (n=1) and microstomia (n=2). CONCLUSION: Computer-aided surgery is an indispensable tool in the reconstruction of SIGSW's. Successfully implemented, it proved to be a useful adjunct for: the restoration of orbital volume, facial projection and symmetry; the inset of composite tissue, and the facilitation of dental implant supported prosthetic rehabilitation.

Updates in Management of Craniomaxillofacial Gunshot Wounds and Reconstruction of the Mandible.

This article includes updates in the management of mandibular trauma and reconstruction as they relate to maxillomandibular fixation screws, custom hardware, virtual surgical planning, and protocols for use of computer-aided surgery and navigation when managing composite defects from gunshot injuries to the face.

Morbidity and Functional Outcomes With Head and Neck Free Flap Reconstruction in Patients Aged 90 Years or Older.

PURPOSE: Morbidity of free tissue transfer in the extremes of age is controversial and not well studied in patients aged 90 years or older because of the rarity of these patients and many clinicians' natural hesitancy to perform such a large operation in patients of this group. The purpose of this study was to answer the following clinical question: Do patients aged 90 years or older who undergo free flap reconstruction have worse functional outcomes than their younger counterparts? MATERIALS AND METHODS: We performed a retrospective chart review of patients aged 90 years or older who underwent free flap reconstruction at Oregon Health and Science University Hospital from 2000 to 2015. All patients aged 90 years or older undergoing free flap reconstruction were included. Patients younger than 90 years during the same period were randomly selected to serve as controls. RESULTS: Free flap reconstructions were performed in 14 patients aged 90 years or older, who were then compared with their randomly selected controls. The only statistically significant difference observed in the outcome variables analyzed was the location of discharge from the hospital, with the older patients more likely to be discharged to a skilled nursing facility (P = .002). However, there was no difference in return-to-baseline level of care at last follow-up between the 2 groups. There also was no statistically significant difference in major or minor medical or surgical complication rates, duration of hospitalization, duration of tracheostomy, return to baseline respiratory status, or return to baseline feeding status between the 2 groups. CONCLUSIONS: Patients aged 90 years or older are more likely to be discharged to a skilled nursing facility than their younger counterparts, but otherwise have similar outcomes in terms of complications and return to baseline function. The results of this study suggest that age 90 years or older should not be a direct contraindication for free flap reconstruction in the head and neck.

Routine Screening Radiography for Retained Wire Following Arch Bar Removal Is Not Indicated.

PURPOSE: To estimate the screening test value of routine radiography after arch bar wire removal by assessing the incidence of retained wires and the importance of their sequelae. MATERIALS AND METHODS: This was a retrospective medical record review. Records of arch bar removal procedures were examined and divided into those screened with radiography after removal (screen group) and those that were not screened (comparison group). The incidence of retained wire was calculated for each group. Study variables included wire-related radiographic or clinical findings. RESULTS: Records of 546 mandible fractures were reviewed; 95 met the study criteria. Most exclusions were due to lack of arch bars, missing postoperative radiographs, or insufficient postoperative documentation. Of the 55 records in the screen group, 1 wire was detected (2%); of the 40 records in the comparison group, 1 wire was detected (3%). The total incidence of retained wire findings was not statistically different between the 2 groups and there were no adverse wire-related sequelae reported by any of the 95 patients. CONCLUSION: Because of the low incidence of retained wires and wire-related sequelae, routine imaging after wire removal is probably not an effective screening test for retained wire and should be limited to situations in which there is clinical suspicion of retained wire.

Survival of microvascular free flaps in mandibular reconstruction: A systematic review and meta-analysis.

BACKGROUND: Free tissue transfer is commonly used in the reconstruction of post-ablative defects of the mandible. Due to lack of statistical power, comparing the survival of various free flaps, even in large studies, is challenging. The purpose of this study was to perform a meta-analysis comparing the survival of the most commonly used free flaps for mandibular reconstruction. METHODS: We searched PubMed, EMBASE, and SCOPUS for relevant studies. A meta-analysis using the Peto one-step odds ratio (OR) with 95% confidence intervals (CI) was used to compare the pooled survival of the most commonly used free flaps for mandibular reconstruction. RESULTS: Of the 25,303 studies reviewed, 17 were selected for data extraction. A total of 1,221 subjects received 1,262 free flaps. Sixty-five free flaps failed. The pooled survival of all free flaps used for mandibular reconstruction was 94.8%. The deep circumflex iliac artery (DCIA) flap was associated with a seven-fold increase in failure when compared to the radial forearm free flap (Peto OR 7.40; 95% CI 1.38, 39.75, P = 0.02). There was no difference in survival when comparing other commonly used free flaps. CONCLUSIONS: The results of this study suggest that free flap reconstruction of the mandible is highly successful. With the exception of the increased survival of the radial forearm when compared to the DCIA, there is no difference in recipient site survival when comparing various free flaps for mandibular reconstruction.

Responsible and prudent imaging in the diagnosis and management of facial fractures.

This article reviews the current standard of care in imaging considerations for the diagnosis and management of craniomaxillofacial trauma. Injury-specific imaging techniques and options for computer-aided surgery as related to craniomaxillofacial trauma are reviewed, including preoperative planning, intraoperative navigation, and intraoperative computed tomography. Specific imaging considerations by anatomic region include frontal sinus fractures, temporal bone fractures, midfacial fractures, mandible fractures, laryngotracheal injuries, and vascular injuries. Imaging considerations in the pediatric trauma patient are also discussed. Responsible postoperative imaging as it relates to facial trauma management and outcomes assessment is reviewed.

Zygoma reconstruction.

Ideal reconstruction of the zygoma position is essential in restoring facial width, projection, and symmetry. Reconstruction should be focused on the zygoma's 4 articulations and restoring the vertical and horizontal pillars of the facial skeleton. This article describes the applied surgical anatomy as it relates to zygomatic deformities, surgical approaches, and reconstruction. The basis for diagnosing and classifying zygoma deformities as they relate to severity of injury and associated displacement, comminution, and comorbidities is also discussed. Traditional and contemporary concepts in posttraumatic, postablative, and esthetic reconstruction are also described.

Cryotherapy and topical minocycline as adjunctive measures to control pain after third molar surgery: an exploratory study.

PURPOSE: To assess the impact of cryotherapy or topical minocycline on patients' perceptions of recovery from pain after third molar surgery in an exploratory comparative-effectiveness study. PATIENTS AND METHODS: Subjects aged at least 14 years who were having all 4 third molars removed were enrolled in 3 separate institutional review board-approved studies. Study groups included subjects treated with a passively applied cold wrap for 24 hours postoperatively, subjects treated with topical minocycline during surgery, and subjects enrolled in a nonconcurrent comparison group who had received neither topical minocycline nor directed cryotherapy. Third molar surgery was performed in all cases by trained surgeons using the same protocol. An exact Kruskal-Wallis test was used to compare the distributions of the worst and average pain scores and a Fisher exact test to compare verbal responses from Gracely pain scales among the 3 groups for postsurgical days (PSDs) 1 to 3. RESULTS: This study comprised 51 cryotherapy subjects (2005-2009), 63 minocycline subjects (2003-2004), and 92 comparison-group subjects (2002-2006) who were treated at academic centers and in community practices across the United States (N = 206). Demographic descriptors were similar among all groups. For PSDs 1 through 3 (unadjusted), the highest scores for worst pain (6-7 [out of 7] on Likert-type scale) were reported less frequently in each of the study groups than in subjects in the comparison group, although the numbers of subjects reporting the highest scores were few. The distribution of pain outcomes was significantly different among the 3 groups for worst pain and affective words on PSD 1 (P = .04 for both). However, the small number of subjects who reported the highest pain scores precluded adequate multivariate statistical analyses for all outcomes on PSD 1 to 3. CONCLUSIONS: Data from this exploratory study suggest that adjunctive therapy to decrease postoperative pain-cryotherapy or topical minocycline-might be effective at moderating the patient's highest pain levels after third molar surgery. The topic should be studied further in a multicenter, prospective, randomized trial.

Recovery after third-molar surgery: the effects of age and sex.

INTRODUCTION: In this study, we assessed the effects of age and sex on quality-of-life recovery after third-molar surgery. METHODS: Healthy subjects scheduled for removal of third molars were recruited at multiple sites for this study. Each patient was given a condition-specific instrument to be completed each postsurgery day for 14 days. Lifestyle and oral-function recovery were assessed by using a 5-point Likert-type scale. Recovery was defined as the number of days until the patient reported no or little trouble. Recovery from pain was defined as the number of days until no medications were taken. For each quality-of-life item, a Cox regression analysis was performed to assess the effects of age and sex on recovery after controlling for surgical-procedure variables. RESULTS: Nine hundred fifty-eight subjects treated at 9 academic centers and 12 community practices were enrolled. Except for ability to open the mouth, recovery for all quality-of-life items for those 21 years or older significantly (P < 0.02) lagged behind recovery for younger subjects. Recovery for female subjects was significantly longer than for male subjects for all outcomes (P < 0.01). CONCLUSIONS: Patients older than 21 and those who are female should be informed before removal of all 4 third molars that their oral function, lifestyle, and pain recovery will be prolonged compared with those who are younger and male.

Third molars and periodontal pathology in American adolescents and young adults: a prevalence study.

PURPOSE: To assess the association between visible third molars and the prevalence of periodontal inflammatory disease of non-third molars. PATIENTS AND METHODS: Subjects aged 14 to 45 years with 4 asymptomatic third molars were enrolled in an institutional review board-approved study. Subjects were classified based on whether at least 1 third molar was visible or all third molars were not visible. Full-mouth periodontal probing depth (PD) data, with 6 sites per tooth, were obtained as a measure of a subject's periodontal status. At least 1 non-third molar PD of 4 mm or greater was indicative of periodontal inflammatory disease. Outcomes for the respective groups were compared by use of Cochran-Mantel-Haenszel row mean score statistics. The level of significance for differences was set at .05. RESULTS: The 342 subjects in the visible group were significantly older, with a median age of 26 years (interquartile range, 22.4-32.2 years), as compared with the 69 subjects in the not visible group, with a median age of 21 years (interquartile range, 18.8-24.9 years) (P < .01). The proportion of males and females was not statistically different between groups (P > .05). Most subjects were white. Significantly more subjects with at least a college education were in the visible group than in the not visible group (P < .01). The rate of tobacco use was low and did not differ between groups. Subjects in the visible group were significantly more likely to have at least 1 PD of 4 mm or greater on non-third molars than those in the not visible group: 59% versus 35%. In both groups, first/second molars were more affected than nonmolars when we controlled for differences in age between groups. CONCLUSIONS: The visible presence of third molars in adolescents and young adults was significantly associated with periodontal inflammatory disease of non-third molars.

Comparison of periodontal inflammatory disease in young adults with and without pericoronitis involving mandibular third molars.

PURPOSE: To compare the prevalence and severity of periodontal inflammatory disease in subjects with pericoronitis involving a mandibular third molar and those without pericoronitis. PATIENTS AND METHODS: Data obtained from healthy adults consecutively enrolled in an institutional review board-approved trial with pericoronitis affecting at least 1 mandibular third molar (study group) were compared with data obtained during the same time frame from subjects without pericoronitis enrolled in a longitudinal third molar monitoring study (comparison group). The periodontal status of each subject was classified based on periodontal probing depths (PD): all PD <4 mm, no disease; 1 to 3 PD >or=4 mm, incipient disease; at least 4 PD >or=4 mm, early disease. Full mouth periodontal probing data were obtained as clinical measures of periodontal status. Data were aggregated to the subject level for the third molar region, the 6 third molar probing sites and the 2 second molar distal probing sites, the non-third molar region, and all remaining probing sites. The prevalence of disease in the study and comparison groups were compared with the Fisher's exact test. As an indicator of disease severity, the number of PD >or=4 mm in the 2 groups were compared by the Kruskal-Wallis test. Level of significance was set at P values less than .05. RESULTS: Median age of the 56 subjects with pericoronitis was 23.3 years (IQR 21.3-26.0 years). Fifty-five percent were Caucasian, 16% African American, and 22% Asian. Males and females were almost equally represented in the study group and in the comparison group. The 194 subjects enrolled without pericoronitis were significantly older (32.8 years; IQR 27.2-40.0 years; P < .001). Eighty-four percent were Caucasian, 10% African American, and 4% Asian. The proportion of subjects with periodontal inflammatory disease in the third molar region was significantly different between the study and comparison groups. Thirty-one percent of the subjects with pericoronitis had incipient and 55% early disease in the third molar region compared with 25% with incipient and 38% with early disease among subjects without pericoronitis (P = .003). The pattern was similar, but the proportion of subjects was not significantly different between the groups for the non-third molar region. In the study group, 32% had incipient disease and 32% early disease compared with 27% with incipient disease and 22% with early disease in the comparison group (P = .09). The median number of PD >or=4 mm for all teeth differed significantly for subjects with and without pericoronitis (median 5 [IQR 3-9] vs 3 [IQR 0-8], respectively; P = .03). CONCLUSION: Pericoronitis involving mandibular third molars may reflect more underlying periodontal inflammatory disease in affected young adults than might be found in young adults with retained third molars and no pericoronitis.

Caries experience and periodontal pathology in erupting third molars.

PURPOSE: This study was conducted to document the prevalence of occlusal caries experience and periodontal pathology for erupting third molars in young adults. PATIENTS AND METHODS: The data are from 49 subjects enrolled in an institutional review board-approved trial with at least one third molar below the occlusal plane at baseline that erupted by longest follow-up. Teeth were considered erupted if they reached the occlusal plane. Caries experience on the occlusal surface of third molars was assessed by a visual-tactile examination. At least 1 periodontal probing depth (PD) >or=4 mm in the third molar region was considered indicative of periodontal pathology. The third molar region was defined as the 6 probing sites around third molars and 2 sites on the distal of second molars. The prevalence of third molar caries experience and periodontal pathology at longest follow-up was assessed. RESULTS: Most of the 49 subjects were female (51%), Caucasian (76%), and educated at least through high school (82%). Median age was 20.5 years (interquartile range [IQR] 18.4 to 24.1 years). Median follow-up was 5.1 years (IQR = 3.4 to 6.9 years). At baseline, none of the subjects had occlusal caries experience in a third molar; 51% of subjects had at least 1 PD >or=4 mm in a third molar region. At follow-up, 27% of the subjects had occlusal caries experience in at least 1 third molar that erupted to the occlusal plane; 61% had at least 1 PD >or=4 mm in a third molar region. Twenty-nine percent had occlusal caries in at least 1 third molar at the occlusal plane and at least 1 PD >or=4 mm in a third molar region. Thirty-seven percent had no third molar occlusal caries experience and all third molar region PD <4 mm. CONCLUSIONS: For third molars that erupted "late," periodontal pathology was more prevalent than occlusal caries.