Does maxillary sinus size affect the risk for zygomatic complex fractures?

The purpose of the study was to measure the maxillary sinus sizes in patients with and without zygomatic bone fractures. In this cross-sectional study computed tomography data of a case group of consecutive treated patients with displaced zygomatic bone fractures were compared to a control group with mandibular fractures. Maxillary sinus sizes were measured in width, height, depth, and volume. We compared sinus sizes between the case and control group, followed by a subgroup analysis of slightly and severely displaced fractures using T-tests. We identified 89 cases, thereof 46 with slightly and 43 with severely displaced fractures. The control group consisted of 110 patients. The mean sinus volume of the case group (19,313 mm3 ± 5237) was significantly larger than in the control group (17,645 mm3 ± 4760; p = 0.02). Subgroup analyses revealed that this difference in volume was more pronounced between patients with severely displaced fractures (20,354 mm3 ± 5416; p = 0.003) and the control group. In two-dimensional measures, only sinus height was significantly greater in the case group (37.41 mm ± 4.25 vs. 35.33 mm ± 4.88; p = 0.002). The same holds for the subgroup with severely displaced fractures (38.27 mm ± 3.91; p = 0.001). Sinus width and depth showed no significant differences between the groups. A maxillary sinus volume larger than 20,000 mm3 is a predictive risk factor for a displaced zygomatic bone fracture. Greater sinus height indicates a larger surface area of the zygomaticomaxillary buttress that decreases the resistance to facial trauma.

A volumetric study of mandibular condyles in orthognathic patients by semiautomatic segmentation.

PURPOSE: This study was conducted to elucidate volumetric data of mandibular condyles of orthognathic patients by analyzing cone beam computed tomography images based upon semiautomatic segmentation. METHODS: Cone beam computed tomography images of 87 patients with malocclusions were analyzed in this retrospective study. Patients were between 17 and 53 years old and diagnosed with Angle class I, II, or III malocclusion. By using the validated open-source software "ITK-SNAP," the volumetric measurements of 174 mandibular condyles were performed. Volumetric analysis was performed according to intra-subject side differences by paired Student t test. In accordance to inter-subject side, gender, age and type of malocclusion differences bivariate analysis and ANOVA were applied. RESULTS: The mean volume for the right condyle was 1.378 ± 0.447 cm3, with a maximum of 2.379 cm3 and a minimum of 0.121 cm3. The mean volume for the left side was 1.435 ± 0.474 cm3, with a maximum of 3.264 cm3 and a minimum of 0.109 cm3. Bivariate analysis indicated a highly significant inter-subject difference between the volume of the left and right mandibular condyles (p < 0.01). Females had a significantly smaller condyle volume than males (p < 0.05 left condyle; p < 0.01 right condyle). CONCLUSION: The fact that shape and volume of mandibular condyles show a high susceptibility to pathological alterations and particularly malocclusions makes a precise knowledge about volumetric changes indispensable. Our results show that significant inter-subject differences in condyle volume could be found with respect to the side and gender. Larger volumes could be assessed for the left condyle and for male patients.

Outcomes of the Nonendoscopic Transoral Approach to Subcondylar Mandible Fractures.

PURPOSE: The transoral approach (TRA) to subcondylar fractures without any endoscopic or transbuccal assistance is not a common technique. The purpose of this study was to measure and compare the quality of open reduction and internal fixation (ORIF) between the TRA and the retromandibular approach (RMB), including types and frequencies of postoperative complications. METHODS: In our retrospective cohort study, we enrolled a sample of patients with displaced subcondylar mandible fractures treated by ORIF. The predictor was the approach mode: TRA or RMB. In postoperative computed tomography (CT) data sets, we measured the angles of the condylar process in relation to references: 1) midline, 2) lateral ramus border, and 3) posterior ramus border. The primary outcome variable was the reduction outcome, which was calculated as the difference between the total of all angles of the operated side and the non-affected side. Secondary outcomes were postoperative complications extracted from patients' files. Other variables were age, gender, number of plates, operation time and a modified AO trauma score. In bivariate analysis, we compared the outcome between both groups. RESULTS: Sixty-four patients were included in total, with TRA performed in 50%. Patients with TRA were younger (31 vs 41, P = .003), and the trauma score was lower (1.9 vs 3.3, P < .001). Reduction outcome remained comparable between both techniques (mean 3.7° for both, P = .92). Complication rates were similar, although facial nerve palsy was absent for TRA (0 vs 4, P = .039). CONCLUSION: We suggest TRA for selected patients with displaced, single fragmented subcondylar fractures. Reduction outcome shows a comparable exactness to RMB, while TRA is safer for the facial nerve.

Volumetric and Morphological Analysis of Mandibular Condyles of Angle Class 2 and 3 Malocclusion Patients.

ABSTRACT: This study was conducted to provide diametric and volumetric data of mandibular condyles from patients with Angle class 2 and 3 malocclusions by semiautomatic segmentation based upon cone-beam computed tomography.Cone-beam computed tomography images of 79 patients were analyzed. By using the open-source software "ITK-SNAP", diametric and volumetric measurements of 158 mandibular condyles were performed. Descriptive statistics were calculated for all normally distributed variables. Correlations between patients with Angle class 2 and 3 were calculated with the independent Student t test. P values P < 0.05 were considered significant.Irrespective of the side, patients with class 2 malocclusion showed smaller mandibular condyles (right: 1.128 ±â€Š0.504 cm3; left: 1.222 ±â€Š0.596 cm3) than patients with class 3 (right: 1.504 ±â€Š0.361 cm3; left: 1.493 ±â€Š0.335 cm3). These results were reproducible also in accordance with the diametric measurement (class 2 right: 16.75 ±â€Š2.72 mm; left: 17.04 ±â€Š3.01 mm) (class 3 right: 18.24 ±â€Š2.54 mm; left: 18.32 ±â€Š2.13 mm). However, volumetric differences were highly statistically significant (right: P = 0.001; left: P = 0.018) while diametric differences were slightly significant for the right and not significant for the left side (right: P = 0.042; left: P = 0.053).Diametric and volumetric analyses offer important additional information based on 3D images of cone-beam computed tomography technology. Significant differences in diameter and volume of mandibular condyles could be assessed between different classes of malocclusion.

Bisphosphonate application and volumetric effects on MRONJ lesions.

The purpose of this investigation was to analyze the volume of medication-related osteonecrosis of the jaw (MRONJ) lesions by semi-automatic segmentation of cone-beam computed tomography images, and correlate the results with the underlying diseases and applied medication. MRONJ lesions detected in cone-beam computed tomography images were assessed. The open-source software ITK-Snap enabled volumetric measurements of MRONJ lesions based on semi-automatic segmentation. Results were analyzed according to necrosis volume, localization, and gender. In addition, the underlying disease and the type of application of antiresorptive medication were investigated. Cone-beam computed tomography images of 66 patients were studied. 34 male and 32 female patients were included, with ages ranging from 50 to 93 years at the time of diagnosis. The mean volume was 993.24 ± 620.94 mm3: 484.73 ± 230.97 mm3 for the upper jaw and 1084.04 ± 625.74 mm3 for the lower jaw. The results indicated statistically significant differences between lesions of the upper and lower jaw, regardless of gender (p = 0.003). The analysis of differences between males and females did not show any significant results (p = 0.464), although males presented slightly larger lesions than females. With regard to the underlying disease, patients with osteoporosis presented larger volumes, whereas patients with malignant tumors presented smaller volumes. Nevertheless, no statistically significant differences according to the underlying disease (p = 0.313) were detected. However, patients with intravenous (iv) application showed statistically significantly larger lesions than patients who underwent oral or subcutaneous (s.c.) applications (p = 0.004). It seems that the osteonecrosis volume correlates with the applied antiresorptive agents. Larger MRONJ lesions should be expected in patients who receive intravenous antiresorptive therapy.

Comparison of two established 2D staging techniques to their appliance in 3D cone beam computer-tomography for dental age estimation.

For medicolegal purposes, orthodontic or orthognathic treatment various stomatological staging technique for age estimation with appliance of conventional radiographic images have been published. It remains uninvestigated if cone beam computer-tomography delivers comparable staging results to the conventional radiographic stages of third molar analysis. We conducted a retrospective cross-sectional study of 312 patients aged 13-21 years. Dental age estimation staging technique, introduced by Nolla and Demirjian, were applied on the left lower third molar imaged by conventional panoramic radiographs and cone beam computer-tomography. It was investigated if 2D and 3D imaging presented different staging results for dental age estimation. In 21% the Demirjian's staging differed by a single stage between 2 and 3D images. The greatest congruence (87%) between 2 and 3D images was revealed for stage 7 (G). In contrary, stage 5 (E) presented the lowest level of congruence with 47.4%. The categorization of Nolla revealed divergences in staging for than two categorical variables in Nolla's stages 3, 4, 5 and 6. In general, the analysis of the data displayed the divergence for Nolla's stages 4-8. The staging results for 2D and 3D imaging in accordance to the rules of Nolla and Demirjian showed significant differences. Individuals of 18 years may present immature third molars, thus merely an immature third molar cannot reject legal majority. Nolla's and Demirjian's 2D and 3D imaging present significantly different staging results.

Mandible Fractures Associated With the Introduction of an E-Scooter-Sharing System.

ABSTRACT: With the introduction of an e-scooter-sharing system in Germany, standing electric scooters became popular modes of transportation in many urban areas. But the increase in popularity has resulted in an increase in traumatic injuries associated with e-scooter accidents. The purpose of this investigation was to determine the common fracture pattern of patients with mandible fractures as a result of an electric scooter accident. The authors performed a retrospective investigation of 52 patients who were admitted to the trauma unit of an oral and maxillofacial department from June until November 2019 with a fracture of the mandible. Our study investigated the first 6 months of e-scooter sharing system in a major city with more than 1 million inhabitants. Our cohort consists of 52 patients, 38 males, and 14 females with a mean age of 37 years. E-scooter related mandible fractures were with 21% the third biggest group, after physical assault and falls. 45% of these patients were intoxicated by alcohol. Furthermore, the majority of e-scooter patients presented more than one fracture of the mandible (73%). For our cohort, a typical combination of a symphysis or body fracture and bilateral affected ramus and/or condyle was the prevalent recorded fracture combination (55%) of e-scooter related traumata. Small scooter wheels, a speed of 15 miles or 20 kilometers per hour and the individual clinging to the handlebar falling predestinate these vehicles for accidents with craniofacial trauma. Among all cranio-facial traumas mandible fractures were mostly documented for e-scooter accidents. The severity of e-scooter related mandible fractures and their fracture pattern should be recognized by trauma units.

Cefazolin versus ampicillin/sulbactam as an empiric antibiosis in severe odontogenic neck infection descending from the lower jaw-retrospective analysis of 350 cases.

OBJECTIVES: Odontogenic infections descending from the lower jaw may lead to severe health conditions. Commonly, a biphasic treatment of surgical drainage and antibiotic therapy is conducted. The choice of the administered empiric antibiotic agent remains debatable. MATERIAL AND METHODS: Retrospectively, we analyzed 350 medical records of patients who were consecutively treated with odontogenic infections descending from the lower jaw. All patients received surgical drainage and either cefazolin or ampicillin/sulbactam as empiric antibiosis. In particular, the number of secondary operations, infectious parameters, and length of in-hospital stay were investigated. RESULTS: The most frequently infected space was the perimandibular/buccal space for both groups followed by the submandibular space. Number of revision procedures, early recurrence, and length of stay presented no significant difference between both groups (p > 0.05). Inflammatory parameters (c-reactive protein, leukocytes) similarly decreased in both groups. CONCLUSION: Cefazolin targets the majority of the pathogens detected in severe odontogenic neck infections descending from the lower jaw and reveals comparable results to AMP/S in regard to the inflammatory parameters and in-hospital stay. CLINICAL RELEVANCE: Cefazolin is a feasible empiric antibiosis for odontogenic neck infections descending from the lower jaw if surgical drainage is performed.

Anatomical and Volumetric Analysis of the Sphenoid Sinus by Semiautomatic Segmentation of Cone Beam Computed Tomography.

ABSTRACT: This investigation was performed to analyze and evaluate anatomical and volumetric data of the sphenoid sinus by semiautomatic segmentation of cone beam computed tomography (CBCT) datasets.This analysis was carried out on cone beam computed tomography images of 100 patients. By using the discretionary software "ITK-Snap", the volumetric investigation of 197 sphenoid sinuses was conducted. The statistical analyses were carried out by using the paired and independent Student t-test. In addition, the Pearsons chi-square test was performed. P values P < 0.05 were considered significant.The volumetric mean was 4.438 ±â€Š2.434 cm3 for the right and 4.809 ±â€Š3.000 for the left side. Results did not indicate statistically significant differences according to the side, irrespective of gender (P > 0.05). The further investigation of differences between male and female patients did assess significant results (P < 0.05), males (10.477 ±â€Š3.851 cm3) present a larger total sinus volume than females (8.219 ±â€Š3.574 cm3). In accordance to patients' age (median 54 years), smaller volumes were related to younger patients and larger volumes to older ones. But, no statistically significant results in accordance to age could be detected (χ2 = 1.258; P > 0.05).Endoscopic sinus surgery of the vulnerable and intricate anatomy of the sphenoid sinus requires an explicit knowledge and orientation about the anatomical variations such as septums and volumetric capacity. Concerning this matter, semiautomatic segmentation of CBCT images can aid the surgeon in preoperative planning. Our investigation shows that a small sinus volume, that is, affecting female patients and a complex sinus anatomy by the occurrence of a septum, especially located close to neurovascular structures could essentially aggravate endoscopic sphenoid sinus surgery. In this regard, volumetric analysis of the sphenoid sinus by CBCT images can provide presurgical information and facilitates an individualized treatment.

The prognostic implications of comorbidity and risk factors for (post)operative complications, days spent in the intensive care unit (ICU), and length of hospitalization in patients with oral squamous cell carcinoma: A prospective study.

BACKGROUND: This study aimed to investigate the prognostic implications of comorbidity/risk factors in a cohort of patients with OSCC. METHODS: The prospective study included patients with biopsy-proven primary OSCC. The impact of potential predictors on (post)operative complications, days spent in the ICU, and length of hospitalization was analyzed using both univariate and multivariate analysis. RESULTS: Using a microvascular free flap (p = 0.009) and tobacco abuse (p = 0.005) had statistically significant impacts on postoperative complications in univariate, but not in multivariate, analysis. The duration of anesthesia (p < 0.001), type of neck dissection (p = 0.014), reconstruction type (p < 0.001), and red blood cell transfusion during operation (p = 0.007) had statistically significant impacts on spending ≥ 3 days in ICU in univariate analysis, with reconstruction type (p = 0.022) and red blood cell transfusion during operation (p = 0.034) having similar impacts in multivariate analysis. The duration of anesthesia (p < 0.001), pT (p = 0.009), type of neck dissection (p = 0.046), reconstruction type (p < 0.001), and microvascular free flap (p < 0.001) had a statistically significant impacts on length of hospitalization in univariate analysis, with reconstruction type (p < 0.001) also having a significant impact in multivariate analysis. CONCLUSION: None of the investigated variables showed a significant effect on the prediction of (post)operative complications according to the Clavien-Dindo classification. The type of reconstruction proved to be a valid predictor for the time spent in ICU as well as for the overall length of hospitalization. Red blood cell transfusion during operation further predicted the time spent in ICU after operation. Both variables should be taken into account when performing a comprehensive planning of the patients' hospitalization.

Does SPECT Provide Incremental Value to CT or MRI in Assessing Mandibular Invasion by Oral Squamous Cell Carcinoma?

PURPOSE: Single photon emission computed tomography (SPECT) has been commonly used as an additional method to assess mandibular bone invasion in patients with oral squamous cell carcinoma (OSCC). In the present study, we measured the diagnostic validity of SPECT findings compared with the histologic findings. PATIENTS AND METHODS: We implemented a retrospective cross-sectional study and enrolled a sample of patients with OSCC adjacent to the mandible. The staging examinations included magnetic resonance imaging (MRI) and/or computed tomography (CT) and additional SPECT. The patients' medical records and imaging data were reviewed by 2 readers, and bone invasion was classified as positive or negative for each diagnostic method. The predictor was bone invasion found on CT and/or MRI compared with the combination of CT and/or MRI with either positive or negative SPECT results. The primary outcome variable was histologic bone invasion. Other variables of interest were clinicopathologic data, type of mandibular resection, and resection margin status. Bivariate tests were used to compare the diagnostic specificity, sensitivity, and accuracy of each imaging modality. RESULTS: The study enrolled 122 patients, with a mean age of 67 years (55% male; study period, January 2010 to December 2017). In 60 patients (49%), segmental mandibular resection was performed. The sensitivity and specificity for bone invasion were 100% and 39% for SPECT and 84% and 75% for CT and/or MRI. The negative results for bone invasion using SPECT did not match the false-positive CT and/or MRI results in 5% (n = 6 of 122). Positive SPECT findings, in addition to positive CT and/or MRI findings increased the sensitivity to 100% but decreased the specificity to 29% (P < .001). Considering only negative SPECT findings increased the specificity to 85% (P = .03), sensitivity remaining unaffected. The accuracy of CT and/or MRI alone was 80% and was 84% when combining CT and/or MRI and negative SPECT findings (P = .03). CONCLUSIONS: In oncologic staging with CT and/or MRI, the addition of SPECT provided only small benefits. Only negative SPECT results allowed for greater specificity and accuracy. The use of SPECT could be considered to rule out bone invasion in cases of radiologic uncertainty of positive CT or MRI findings.

Volumetric analysis of MRONJ lesions by semiautomatic segmentation of CBCT images.

PURPOSE: The purpose of this study was to evaluate potential differences in volumes of areas of osteolysis caused by medication-related osteonecrosis of the jaw (MRONJ) between the upper and lower jaw. We aim to analyze the clinical relevance of volumetric measurement of osteolytic lesions for surgical planning of MRONJ patients. METHODS: Sixty-seven patients who were clinically and histopathologically diagnosed with MRONJ were retrospectively included in this study. Cone beam computed tomography (CBCT) images were evaluated according to localization, affected anatomical structures, and volumetric measurement of osteolytic lesions caused by MRONJ in appliance of CBCT datasets by using ITK-SNAP. RESULTS: The most frequently affected localization is the mandible, whereas female patients show significantly more often lesions of the maxilla. The cortical bone was predominantly affected. Furthermore, the affection of teeth, sinus floor, inferior alveolar nerve canal, or even a pathological fracture of the mandible are infrequently existing. The volumetric measurements revealed a statistically significant greater absolute osteolysis volume in males. CONCLUSIONS: Image analysis and volumetric measurements of osteolytic lesions of MRONJ patients is a helpful tool to further understand the clinical appearance and identify compromised anatomic landmarks. Volumetric analysis aids in pre-surgical planning and visualizes the individual extent of the disease for each patient.

Comparison of MRI with dedicated head and neck signal amplification coil and cone beam computed tomography: MRI is a useful tool in diagnostics of cranio-facial growth disorders.

OBJECTIVE: Magnetic resonance imaging (MRI) shows excellent image quality for the depiction of soft tissues and is therefore an important imaging technique in medical diagnostics. However, the practical simultaneous presentation of hard and soft tissue structures of the mouth, jaw and facial area is not fully satisfactory at this time. We investigated the image quality of 1.5 T MRI using a dedicated signal amplifying coil for the application in the oral and maxillofacial field of and compared it with cone beam computed tomography (CBCT). We hypothesized that imaging quality for growth disorders of the facial skull does not differ significantly between the two imaging techniques. MATERIALS AND METHODS: 12 patients were consecutively enrolled into this study between 01/2016 and 12/2017. Patients received diagnostic imaging for clinical indications using 1,5 T MRI using a dedicated head and neck coil for signal amplification as well as an CBCT. For each patient 5 different MRI sequences and one CBCT protocol were assessed. Images were evaluated by a radiologist and a dentist in consensus. On the basis of 51 anatomical structures and orthodontic, cephalometric reference points, the five datasets were subjectively rated and compared to the CBCT dataset. RESULTS: Patient age was in the range of 19-78 years. 2614 (69.8%) out of 3744 possible valuations were assessable. Compared to CBCT, MRI images were rated to have a superior image quality of presentation for 42 out of 51 anatomic structures (p < 0.05). Notably, 5 out of 51 structures were not assessable due to missing values. T1-weighted MRI images were rated superiorly to T2-weighted images in displaying anatomically relevant landmarks in the oral and maxillofacial field. MRI datasets were inferior in imaging cephalometric and orthodontic reference points in comparison to CBCT images. CONCLUSION: In conclusion, this pilot study demonstrates that radiation-free dental MRI enables a reliable detection of important anatomical structures. Thus, the signal amplified MRI presents a radiation-free imaging alternative to established CBCT in craniofacial growth disorders protocols. However, imaging quality in MRI datasets remains inferior to CBCT images for cephalometric and orthodontic reference points.

Risk of frontal sinus anterior table fractures after craniofacial trauma and the role of anatomic variations in frontal sinus size: A retrospective case-control study.

INTRODUCTION: Purpose of this study was to evaluate a probable risk of frontal sinus size for traumatic depressed anterior table fractures in patients with similar forehead trauma. METHODS: We conducted a retrospective case-control study with a case group of consecutive treated patients with displaced frontal sinus anterior table fractures. The control group was randomly sampled from patients who presented with a blunt forehead trauma in our institution's emergency unit. In computed tomography data sets, all patients' frontal sinus size was categorized by Guerram's classification that is defined as aplasia, hypoplasia, medium-size and hyperplasia. Odds for prevalence of the sinus types as well as sinus total width and height were compared between both groups. RESULTS: In total, 47 cases and 93 controls were identified. Hyperplasia in the case group had an odds ratio of 46:1 (p < 0.001) compared to the controls. Mean sinus width (73 mm vs. 46 mm; p < 0.001) and sinus height (30 mm vs. 15 mm; p < 0.001) were larger in the case group. CONCLUSION: Depressed traumatic fractures of the anterior table are an injury with a high risk specific for enlarged frontal sinus sizes. Anatomy is the predictive factor for this mode of craniofacial trauma.

Microbial diversity in infections of patients with medication-related osteonecrosis of the jaw.

OBJECTIVES: A central role of infections in the treatment of MRONJ patients is widely accepted. An investigation of the MRONJ lesions' biofilms as potential pathogens seems logical. MATERIALS AND METHODS: We investigated the clinical data of our MRONJ patients who received surgery in advanced stage of the disease. Special attention was granted to the local colonizers harvested from osseous MRONJ specimens and submucosal putrid infections. RESULTS: Eleven out of 71 patients presented a spontaneous onset of the disease and for 60 out of 71 patients a trigger was detected. Breast cancer (29.6%) and prostate cancer (22.5%) were the most frequent underlying disease for prescription of an antiresorptive therapy, mostly zoledronate. Submucosal soft tissue biofilms significantly differed from biofilms harvested from the MRONJ lesions bottom, yet the most frequent bacteria were equally present in both groups: Streptococcus species (spp.), Prevotella spp., Actinomyces spp., Veillonella spp., and Parvimonas micra. The cephalosporins, cefuroxime and cefotaxime, and ß-lactam antibiotics with ß-lactamase inhibitor revealed the greatest susceptibility for the detected bacteria. CONCLUSION: The bacteria from the submucosal areas and the bottom of the infected bone presented comparable susceptibility to the common antibiotics regimes. Streptococcus spp., Prevotella spp., and Veillonella spp. present a high abundance in MRONJ lesions beside Actinomyces spp. The MRONJ lesions bottom is in many cases not infected by Actinomyces spp. CLINICAL RELEVANCE: The removal of the necrotic bone reduces the variety of bacteria found in MRONJ lesions, in particular at the bottom of the lesion.

Intraoperative Ultrasound Control of Zygomatic Arch Fractures: Does Additional Imaging Improve Reduction Quality?

PURPOSE: Intraoperative navigation to assess anatomic reduction is the general trend in maxillofacial trauma surgery. The aim of this study was to evaluate the closed reduction outcome of isolated zygomatic arch fractures using ultrasound compared with palpation control. MATERIALS AND METHODS: In this case-and-control study, the authors identified consecutively treated patients who underwent closed reduction of isolated zygomatic arch fractures using the Volkmann reposition hook with intraoperative ultrasound. Controls were patients with the same diagnosis and surgical procedure without ultrasound imaging. Pre- and postoperative radiographic datasets were geometrically analyzed. The outcome variables postoperative cortical step, persistent postoperative displacement, and overall grade of reduction were compared in the 2 study groups. Subgroups of fracture patterns were classified as M-shaped or variable. Statistical analysis was performed using t test for continuous variables and 2-sided χ2 test for categorical variables, with a P value less than .05 defined as significant. RESULTS: Sixteen cases with intraoperative ultrasound and 60 controls were identified from the institution's database. The angle of postoperative displacement was significantly decreased in the ultrasound group for all fractures (2.4° vs 5.3°; P = .004) and the variable fracture type (1.6° vs 8.1°; P = .005). Overall grade of reduction was improved in the ultrasound group for all fractures (P = .03) but with no difference solely for M-shaped fractures (P = .37). CONCLUSIONS: Although reduction control using palpation and probing using the Volkmann hook showed satisfactory results for M-shaped fractures, additional intraoperative ultrasound imaging showed promise for increasing success rates for the variable type of zygomatic arch fracture.

Frontal Sinus Morphology: A Reliable Factor for Classification of Frontal Bone Fractures?

PURPOSE: The frontal sinus shows a wide range of morphologic variations. The aim of this study was to evaluate the influence of frontal sinus size on fracture characteristics in frontal bone trauma. MATERIALS AND METHODS: In this cross-sectional study, data from patients with traumatic fractures of the frontal bone were retrospectively collected from the institution's database. Radiometric analysis of computed tomography and cone-beam computed tomography datasets was performed. Frontal sinus size was measured as variables of height, width, and depth. The secondary predictor was morphologic sinus type according to Guerram's classification: hyperplasia, medium size, hypoplasia, or aplasia of the frontal sinus. To determine outcomes, we classified fractures into the following categories: fracture isolated to the anterior table, combined fractures of the anterior and posterior tables, fracture isolated to the posterior table, and frontal bone fracture without sinus involvement. Further study variables were patients' demographic characteristics, combined midfacial fractures, orbital rim involvement, fracture displacement, and surgical approach. For statistical analysis, fracture types were assessed for frontal sinus metric size and morphologic type using bivariate tests with P < .05 defined as significant. RESULTS: We enrolled 53 consecutive patients with a mean age of 35 years; male patients comprised 91%. Fracture types differed significantly in sinus width and height (both P < .001), as well as depth (P = .002). Frontal sinus morphology was hyperplastic in 66%, medium in 30.2%, and hypoplastic in 3.8%. Patients with a hyperplastic frontal sinus had an increased likelihood of isolated anterior table fractures (odds ratio, 6.0; P = .007) compared with medium-sized types. Fractures without sinus involvement were more likely in hypoplastic and medium types (P < .001). CONCLUSIONS: The morphology of the frontal sinus determines the probability of fracture types from craniofacial trauma. Thus the frontal sinus size appears to be a major factor for frontal bone resistance to traumatic force impingement.

Prevention and management of bacterial infections of the donor site of flaps raised for reconstruction in head and neck surgery.

PURPOSE: In the field of reconstructive head and neck surgery, surgical site infections (SSI) are commonly investigated for the recipient site of various reconstructive procedures. Data about SSI of the donor site of different flaps raised for reconstruction are rare. MATERIAL AND METHODS: With regard to the bacterial donor site infections, we retrospectively investigated the medical data, surgical reports and wound management protocols of 267 patients who received reconstruction of the head and neck after ablative surgery. All patients underwent reconstruction with one of the following flaps: free fasciocutaneous radial forearm flap (RFFF), free fasciocutaneous anterolateral thigh flap (ALTFF), pedicled myocutaneous latissimus dorsi flap (PLDF), pedicled myocutaneous pectoralis major flap (PPMF), free osteocutaneous fibula flap (FFF). Follow-up was conducted for 12 months. RESULTS: The lowest detection ratio (DR: number of infected sites/flaps raised from the respective donor site) was calculated for the radial forearm, 0.087. Pedicled flaps presented a moderate DR (PLDF: 0.27, PMMF:0.35). Donor sites of the leg possessed the highest DR (ALTFF:0.61, FFF: 045). Mainly gram-positive facultative anaerobic bacteria (n = 41) were detected and gram-negative bacteria (aerobe/anaerobe) were present in 27 cases. The most frequently detected bacteria were Staphylococcus spp., Viridans Streptococci, Pseudomonas aeruginosa and Escheria coli. Continuous wound management for in-hospital patients was able to prevent any local spreading or a prolonged length of in-hospital stay. CONCLUSION: Overall, gram-positive facultative anaerobic bacteria, mainly Staphylococcus spp., are the predominant bacteria detected in donor site wounds. For wound care management, an infection with gram-negative pathogens should not be neglected.

Radiomorphometric analysis of isolated zygomatic arch fractures: A comparison of classifications and reduction outcomes.

PURPOSE: Although different proposals have been made to categorize isolated zygomatic arch fractures (ZAF), an investigation about fracture type and clinical outcome has not been published. In this study, we analyzed the geometric fracture morphology in isolated ZAF and provide a survey of reduction outcomes in accordance with 4 independent classifications. MATERIALS AND METHODS: Geometric measurements were performed in radiologic images of 94 patients with isolated ZAF, which were consecutively treated by closed reduction over transbuccal approach. Fracture types were allocated to the classifications of Rowe and Williams, Honig and Merten, Yamamoto et al., and Ozyazgan et al. The odds of achieving a satisfactory outcome were calculated for all categories. RESULTS: Wide preoperative dislocation angles of more than 22° presented in M-type fractures (77.1%) more frequently compared to 2 fragments without the M-shape (33.3%) and one fragment (14.8%, p < 0.001). Favorable reduction outcome was significantly higher for M-shaped fractures than for differently configured fractures (83.3% vs. 30.4%, odds ratio 11.43, confidence interval 4.27-30.61). The rate of reduction in 100%-75% was most frequent for the Honig and Merten type I as well as Ozyazgan type IBV (both 85.4%, p < 0.001) and Yamamoto type II (84.2%, p < 0.001). CONCLUSION: The classifications of Honig and Merten, Yamamoto et al., and Ozyazgan were quite applicable, and subgroups showed significant increments in reduction outcome. Our analysis emphasizes that the differentiation of two clinical relevant groups, M-shaped and variable arch fractures, is feasible to manage and efficient to determine the odds of reduction outcome.

Supportive topical tranexamic acid application for hemostasis in oral bleeding events - Retrospective cohort study of 542 patients.

PURPOSE: Tranexamic acid (TXA) is widely used in the prevention of postsurgical oral bleeding. Tranexamic acid in addition to further surgical measures is widely utilized in prevention of post-surgical oral bleeding. The aim of the present study was to investigate: Can oral hemostasis be achieved by merely compression and topical application of tranexamic acid in different anticoagulant regimes among patients attending a general emergency department? Where are the limits to this procedure? Which has the greater impact on surgeons' choice for an invasive hemostatic approach-bleeding quality or oral anticoagulant therapy? MATERIALS AND METHODS: A retrospective cohort study of 542 patients who consecutively received treatment for oral bleeding was performed. We surveyed the values of the diverse hemostatic approaches. Special attention was granted to patient anticoagulant regimen and quality of the oral bleeding event. RESULTS: A total of 199 of 542 (36.7%) oral bleeding events were stopped by compression with a gauze or gauze soaked with TXA (4.8%). Stopping an oral bleeding event with wound compression can be improved by factor 1.6 if the gauze is soaked with tranexamic acid (4.8%), p ≤ 0.05. LMWH presented significantly more moderate bleeding than bloody oozing of the wound, p < 0.05. The quality of bleeding had a strong influence on oral surgeons' decisions to apply further surgical means. Sutures and native collagen fleeces were the favored methods to stop moderate and severe bleeding (p < 0.05). CONCLUSION: Topical application of TXA aids as a useful supportive tool to stop mild bleeding events such as the bloody oozing of an oral wound. The quality of an oral bleeding episode should be considered in the choice of hemostatic measure. Hemostatic approaches should begin with the least invasive procedure. TXA is a helpful tool.