Current Strategies for Treatment of Mandibular Fractures With Plate Osteosynthesis: A European Prospective Study.

PURPOSE: The training and preferences of surgeons influence the type of surgical treatment for mandibular fractures. This multicentre prospective study analyzed the current treatment strategies and outcomes for mandibular fractures with open reduction and internal fixation (ORIF). MATERIAL AND METHODS: This prospective study included patients aged ≥16 years who underwent ORIF for mandibular fractures in 12 European maxillofacial centers. Age, sex, pretrauma dental status, fracture cause, site and type, associated facial fractures, surgical approach, plate number and thickness (≤1.4 or ≥1.5 mm), duration of postoperative maxillomandibular fixation, occlusal and infective complications at 6 weeks and 3 months, and revision surgeries were recorded. RESULTS: Between May 1, 2021 and April 30, 2022, 425 patients (194 single, 182 double, and 49 triple mandibular fractures) underwent ORIF for 1 or more fractures. Rigid osteosynthesis was performed for 74% of fractures and was significantly associated with displaced (P=0.01) and comminuted (P=0.03) fractures and with the number of nonsurgically treated fracture sites (P=0.002). The angle was the only site associated with nonrigid osteosynthesis (P<0.001). Malocclusions (5.6%) and infective complications (5.4%) were not associated with osteosynthesis type. CONCLUSION: Rigid osteosynthesis was the most frequently performed treatment at all fracture sites, except the mandibular angle, and was significantly associated with displaced and comminuted fractures and the number of nonsurgically treated fracture sites. No significant differences were observed regarding postoperative malocclusion or infections among osteosynthesis types.

Accuracy of surgical navigation for patient-specific reconstructions of orbital fractures: A systematic review and meta-analysis.

OBJECTIVE: This systematic review and meta-analysis aimed to review the recent literature on the technical accuracy of surgical navigation for patient-specific reconstruction of orbital fractures using a patient-specific implant, and to compare surgical navigation with conventional techniques. MATERIALS AND METHODS: A systematic literature search was conducted in PubMed (Medline), Embase, Web of Science, and Cochrane (Core Collection) databases on May 16, 2023. Literature comparing surgical navigation with a conventional method using postoperative three-dimensional computed tomography imaging was collected. Only articles that studied at least one of the following outcomes were included: technical accuracy (angular accuracy, linear accuracy, volumetric accuracy, and degree of enophthalmos), preoperative and perioperative times, need for revision, complications, and total cost of the intervention. MINORS criteria were used to evaluate the quality of the articles. RESULTS: After screening 3733 articles, 696 patients from 27 studies were included. A meta-analysis was conducted to evaluate volumetric accuracy and revision rates. Meta-analysis proved a significant better volumetric accuracy (0.93 cm3 ± 0.47 cm3) when surgical navigation was used compared with conventional surgery (2.17 cm3 ± 1.35 cm3). No meta-analysis of linear accuracy, angular accuracy, or enophthalmos was possible due to methodological heterogeneity. Surgical navigation had a revision rate of 4.9%, which was significantly lower than that of the conventional surgery (17%). Costs were increased when surgical navigation was used. CONCLUSION: Studies with higher MINORS scores demonstrated enhanced volumetric precision compared with traditional approaches. Surgical navigation has proven effective in reducing revision rates compared to conventional approaches, despite increased costs.

Augmented and Virtual Reality for Preoperative Trauma Planning, Focusing on Orbital Reconstructions: A Systematic Review.

BACKGROUND: This systematic review summarizes recent literature on the use of extended reality, including augmented reality (AR), mixed reality (MR), and virtual reality (VR), in preoperative planning for orbital fractures. METHODS: A systematic search was conducted in PubMed, Embase, Web of Science and Cochrane on 6 April 2023. The included studies compared extended reality with conventional planning techniques, focusing on computer-aided surgical simulation based on Computed Tomography data, patient-specific implants (PSIs), fracture reconstruction of the orbital complex, and the use of extended reality. Outcomes analyzed were technical accuracy, planning time, operative time, complications, total cost, and educational benefits. RESULTS: A total of 6381 articles were identified. Four articles discussed the educational use of VR, while one clinical prospective study examined AR for assisting orbital fracture management. CONCLUSION: AR was demonstrated to ameliorate the accuracy and precision of the incision and enable the better identification of deep anatomical tissues in real time. Consequently, intraoperative imaging enhancement helps to guide the orientation of the orbital reconstruction plate and better visualize the precise positioning and fixation of the PSI of the fractured orbital walls. However, the technical accuracy of 2-3 mm should be considered. VR-based educational tools provided better visualization and understanding of craniofacial trauma compared to conventional 2- or 3-dimensional images.

Manual versus rigid intraoperative maxillo-mandibular fixation in the surgical management of mandibular fractures: A European prospective analysis.

PURPOSE: Intraoperative stabilisation of bony fragments with maxillo-mandibular fixation (MMF) is an essential step in the surgical treatment of mandibular fractures that are treated with open reduction and internal fixation (ORIF). The MMF can be performed with or without wire-based methods, rigid or manual MMF, respectively. The aim of this study was to compare the use of manual versus rigid MMF, in terms of occlusal outcomes and infective complications. MATERIALS AND METHODS: This multi-centric prospective study involved 12 European maxillofacial centres and included adult patients (age ≥16 years) with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate or partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, modality of intraoperative MMF (manual or rigid), outcome (minor/major malocclusions and infective complications) and revision surgeries. The main outcome was malocclusion at 6 weeks after surgery. RESULTS: Between May 1, 2021 and April 30, 2022, 319 patients-257 males and 62 females (median age, 28 years)-with mandibular fractures (185 single, 116 double and 18 triple fractures) were hospitalised and treated with ORIF. Intraoperative MMF was performed manually on 112 (35%) patients and with rigid MMF on 207 (65%) patients. The study variables did not differ significantly between the two groups, except for age. Minor occlusion disturbances were observed in 4 (3.6%) patients in the manual MMF group and in 10 (4.8%) patients in the rigid MMF group (p > .05). In the rigid MMF group, only one case of major malocclusion required a revision surgery. Infective complications involved 3.6% and 5.8% of patients in the manual and rigid MMF group, respectively (p > .05). CONCLUSION: Intraoperative MMF was performed manually in nearly one third of the patients, with wide variability among the centres and no difference observed in terms of number, site and displacement of fractures. No significant difference was found in terms of postoperative malocclusion among patients treated with manual or rigid MMF. This suggests that both techniques were equally effective in providing intraoperative MMF.

European multicenter prospective analysis of the use of maxillomandibular fixation for mandibular fractures treated with open reduction and internal fixation.

INTRODUCTION: The goal of mandibular fracture treatment is to restore static and dynamic occlusal functions. Open reduction and internal fixation (ORIF) of these fractures can be associated with an intraoperative and/or postoperative maxillo-mandibular fixation (MMF). The aim of this study was to analyse the use of perioperative MMF and its effects on occlusal outcomes in the management of mandibular fractures. MATERIAL AND METHODS: This multicentric prospective study included adult patients with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate, partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, type of ORIF (rigid, non-rigid or mixed), thickness and number of plates, modality of intraoperative MMF (arch bars, self-tapping and self-drilling screws [STSDSs], manual, other) and duration of postoperative MMF. The primary outcome was malocclusion at 6 weeks and 3 months. Statistical analyses were performed with Fisher's exact test or chi-square test, as appropriate. RESULTS: Between 1 May 2021 and 30 April 2022, 336 patients, 264 males and 72 females (median age, 28 years) with mandibular fractures (194 single, 124 double and 18 triple fractures) were hospitalized. Intraoperative MMF was performed in all patients. Osteosynthesis was rigid in 75% of single fractures, and rigid or mixed in 85% and 100% of double and triple fractures, respectively. Excluding patients who underwent manual reduction, postoperative MMF (median duration, 3 weeks) was performed in 140 (64%) patients, without differences by type or number of fractures (p > 0.05). No significant difference was found in the incidence of malocclusion in patients with postoperative MMF (5%, 95% confidence interval [CI], 2-10%) compared to those without (4%; 95% IC, 1-11%) (p > 0.05). CONCLUSION: Postoperative MMF was performed in more than half of the patients despite adequate fracture osteosynthesis, with wide variability amongst centers. No evidence of a reduction in the incidence of postoperative malocclusion in patients treated with postoperative MMF was found.

Delayed onset peripheral facial nerve palsy after dental extraction: a case report and literature review.

Peripheral facial nerve palsy (PFP) is a rare occurrence after dental extraction. Early onset PFP after the procedure can be caused by trauma and/or local anesthesia, whereas delayed onset PFP has more speculative etiologies. The latter has a certain affiliation to Bell's palsy and is therefore primarily treated with corticosteroids, and long-term follow-up is often warranted. This article reports a unique case of a 30-year-old woman developing a delayed onset right-sided PFP after local intraoral anesthetic injection for molar extraction. Facial nerve injury was identified with signs of denervation and neuritis and the patient was treated with nonsteroidal anti-inflammatory drug, corticosteroids, vitamin B supplements, and mime therapy. After 9 months, the patient showed an improvement of the facial muscle activity and went from a grade IV to a grade III on the House-Brackmann grading scale.

Can L-PRF be helpful for delayed deep wound healing after a tracheotomy or lymph node dissection in a pN0 status?: A case report.

INTRODUCTION AND IMPORTANCE: Leukocyte platelet-rich fibrin (L-PRF) is used for its ability to deliver high concentrations of autologous growth factors to host tissues, to promote tissue repair. CASE PRESENTATION: This report describes the case of a 48-year-old woman with tongue cancer treated surgically (pT3pN0), who experienced a delay of five weeks in the process of deep wound healing after a tracheotomy and cervical lymph node dissection that was treated with L-PRF. The patient had no risk factors for delayed wound healing, except for active preoperative smoking. Several attempts were made to stimulate bleeding and edge-to-edge closure, without conclusive results. However, five days after L-PRF placement, the subcutaneous tissues were adhering to the deep planes in both wounds. Fifteen days after L-PRF treatment, a complete wound healing was observed which allowed initiation of postoperative radiotherapy. CLINICAL DISCUSSION: This case report questions the potential of L-PRF for patients with a pN0 status, not only in superficial wounds, but also in deep wound healing. However, the use of L-PRF for patients with a pN1 status is not recommended, given the possible presence of tumour cells in the tissues, and the activation of these tumour cells by the growth factors present in L-PRF. CONCLUSION: This report supports the idea that L-PRF can contribute to deep soft tissue healing for patients with a pN0 status due to its positive clinical healing effects.

Accuracy of virtual planning and intraoperative navigation in zygomaticomaxillary complex fractures: A systematic review.

OBJECTIVE: This systematic review aims to investigate the effect of virtual planning on the treatment of zygomaticomaxillary complex (ZMC) traumatology followed by intraoperative navigation. Furthermore, clinical outcomes following intraoperative navigation surgery or conventional surgery will be compared. MATERIALS AND METHODS: A systematic literature search was conducted in PubMed, Embase, Web-of-Science, and Cochrane on January 1st, 2022. Inclusion criteria were articles using preoperative three-dimensional (3D) virtual planning combined with intraoperative navigation or comparing these 3D methods with conventional methods. Furthermore, at least one of the following outcomes needed to be included in the article: technical accuracy of the procedure, preoperative planning time, operative time, number of fixation points, patient satisfaction, complications, or total costs of the intervention. RESULTS: Following the screening of 4478 articles, 17 were included. Five articles appeared to indicate a significantly better technical linear accuracy, one article reported better accuracy for rotation and two articles showed better accuracy in restoring orbital volume when using navigation. Nine articles investigated operative time with varying results. Seven articles calculated the additional costs, of which three concluded no extra cost while the others indicated high additional costs or questionable cost-effectiveness. CONCLUSION: Virtual planning and intraoperative navigation technologies have the potential to assist maxillofacial trauma surgeons in reducing ZMC fractures significantly more accurately and restoring the facial contour in a less invasive manner at an acceptable cost. REGISTRATION: The protocol for this systematic review (CRD42020216717) was registered in the International Prospective Register of Systematic Reviews (PROSPERO).

Incidence, Aetiology, and Associated Fracture Patterns of Infraorbital Nerve Injuries Following Zygomaticomaxillary Complex Fractures: A Retrospective Analysis of 272 Patients.

Study Design: Retrospective study. Objective: Zygomaticomaxillary complex (ZMC) fractures are common facial injuries with heterogeneity regarding aetiologies, fracture types, infraorbital nerve (ION) involvement, and treatment methods. The aim of this study was to identify associations between aetiologies, fracture types, and neurological complications. Additionally, treatment methods and recovery time were investigated. Methods: Medical files of 272 patients with unilateral and bilateral ZMC fractures were reviewed, whose cases were managed from January 2014 to January 2019 at the Department of Oral and Maxillofacial Surgery, University hospitals Leuven, Belgium. History of ION sensory dysfunction and facial nerve motoric dysfunction were noted during follow-up. Results: ION hypoaesthesia incidence was 37.3%, with the main causes being fall accidents, road traffic accidents, and interpersonal violence. Significant predictors of ION hypoaesthesia were Zingg type B fractures (P = 0.003), fracture line course through the infraorbital canal (P < .001), orbital floor fracture (P < 0.001), and ZMC dislocation or mobility (P = 0.001). Conclusion: Of all ZMC fractures, 37.3% exhibited ION hypoaesthesia. Only ZMC Zingg type B fractures (74.0%) were significantly more associated with ION hypoaesthesia. ION hypoesthesia was more likely (OR = 2.707) when the fracture line course ran through the infraorbital canal, and was less dependent on the degree of displacement. Neuropathic pain symptoms developed after ZMC fractures in 2.2% patients, posing a treatment challenge. Neuropathic pain symptoms were slightly more common among women, and were associated only with type B or C fractures. No other parameters were found to predict the outcome of this post-traumatic neuropathic pain condition.

A time-driven activity-based costing approach for identifying variability in costs of childbirth between and within types of delivery.

BACKGROUND: Recently, time-driven activity-based costing (TDABC) is put forward as an alternative, more accurate costing method to calculate the cost of a medical treatment because it allows the assignment of costs directly to patients. The objective of this paper is the application of a time-driven activity-based method in order to estimate the cost of childbirth at a maternal department. Moreover, this study shows how this costing method can be used to outline how childbirth costs vary according to considered patient and disease characteristics. Through the use of process mapping, TDABC allows to exactly identify which activities and corresponding resources are impacted by these characteristics, leading to a more detailed understanding of childbirth cost. METHODS: A prospective cohort study design is performed in a maternity department. Process maps were developed for two types of childbirth, vaginal delivery (VD) and caesarean section (CS). Costs were obtained from the financial department and capacity cost rates were calculated accordingly. RESULTS: Overall, the cost of childbirth equals €1894,12 and is mainly driven by personnel costs (89,0%). Monitoring after birth is the most expensive activity on the pathway, costing €1149,70. Significant cost variations between type of delivery were found, with VD costing €1808,66 compared to €2463,98 for a CS. Prolonged clinical visit (+ 33,3 min) and monitoring (+ 775,2 min) in CS were the main contributors to this cost difference. Within each delivery type, age, parity, number of gestation weeks and education attainment were found to drive cost variations. In particular, for VD an age >  25 years, nulliparous, gestation weeks > 40 weeks and higher education attainment were associated with higher costs. Similar results were found within CS for age, parity and number of gestation weeks. CONCLUSIONS: TDABC is a valuable approach to measure and understand the variability in costs of childbirth and its associated drivers over the full care cycle. Accordingly, these findings can inform health care providers, managers and regulators on process improvements and cost containment initiatives.

Condylar Fractures: An Argument for Conservative Treatment.

INTRODUCTION: The treatment of mandibular condyle fractures remains a controversial topic in maxillofacial surgery. No uniform treatment protocol is currently available. PURPOSE: We performed a retrospective monocentric cohort study of patients with condylar fractures and their treatment, including long-term follow-up by telephone, followed by a short review of the literature. PATIENTS AND METHODS: The available data on condylar fractures presenting at Leuven University Hospitals between January 1, 2009, and December 31, 2015, were analyzed. Cause, age, sex, fracture level, degree of displacement, associated facial fractures, malocclusion, type of treatment, and complications were noted. Follow-up by telephone was performed after an average 261 weeks for the conservative group. RESULTS: A total of 109 condylar fractures were observed with a male/female ratio of 1.14:1. Most fractures were subcondylar, unilateral, displaced, caused by road traffic accidents, and treated conservatively. DISCUSSION: In children and intracapsular fractures, conservative management remains the first choice. Maxillomandibular fixation should be used sparingly in children and for as short a time as possible. Some patients indicated for surgery can still have acceptable results if treated conservatively.

Subperiosteal orbital abscess from odontogenic origin: A case report.

INTRODUCTION: Subperiosteal orbital abcess is a rarely reported complication of odontogenic infections and can be associated visual impairment and neurological symptoms. Because of fast infection spreading, delay in diagnosis and treatment can result in permanent damage. PRESENTATION OF CASE: A 55-year old presented with a right-sided subperiosteal orbital abscess originating from a decayed first upper molar. The associated loss of vision improved only after a extraoral surgical drainage. Three years later, recurrent headaches, photobia and ptosis still persist. DISCUSSION: Our case demonstrates a rare but potentially hazardous complication of untreated dental infections. The effect of antibiotics is often overestimated, and lack of treatment may lead to serious sequelae, certainly when the orbital infection is located posterior to the orbital septum. When intraoral drainage is insufficient, the infection should be accessed extraorally. CONCLUSION: Orbital infections require a thorough clinical evaluation, including the oral cavity as dental infections may be overlooked. Dental radiograpy plays a major role. Prompt and adequate treatment is crucial in preventing further spreading of odontogenic infections.

Constitutive IP3 signaling underlies the sensitivity of B-cell cancers to the Bcl-2/IP3 receptor disruptor BIRD-2.

Anti-apoptotic Bcl-2 proteins are upregulated in different cancers, including diffuse large B-cell lymphoma (DLBCL) and chronic lymphocytic leukemia (CLL), enabling survival by inhibiting pro-apoptotic Bcl-2-family members and inositol 1,4,5-trisphosphate (IP3) receptor (IP3R)-mediated Ca2+-signaling. A peptide tool (Bcl-2/IP3R Disruptor-2; BIRD-2) was developed to abrogate the interaction of Bcl-2 with IP3Rs by targeting Bcl-2's BH4 domain. BIRD-2 triggers cell death in primary CLL cells and in DLBCL cell lines. Particularly, DLBCL cells with high levels of IP3R2 were sensitive to BIRD-2. Here, we report that BIRD-2-induced cell death in DLBCL cells does not only depend on high IP3R2-expression levels, but also on constitutive IP3 signaling, downstream of the tonically active B-cell receptor. The basal Ca2+ level in SU-DHL-4 DLBCL cells was significantly elevated due to the constitutive IP3 production. This constitutive IP3 signaling fulfilled a pro-survival role, since inhibition of phospholipase C (PLC) using U73122 (2.5 µM) caused cell death in SU-DHL-4 cells. Milder inhibition of IP3 signaling using a lower U73122 concentration (1 µM) or expression of an IP3 sponge suppressed both BIRD-2-induced Ca2+ elevation and apoptosis in SU-DHL-4 cells. Basal PLC/IP3 signaling also fulfilled a pro-survival role in other DLBCL cell lines, including Karpas 422, RI-1 and SU-DHL-6 cells, whereas PLC inhibition protected these cells against BIRD-2-evoked apoptosis. Finally, U73122 treatment also suppressed BIRD-2-induced cell death in primary CLL, both in unsupported systems and in co-cultures with CD40L-expressing fibroblasts. Thus, constitutive IP3 signaling in lymphoma and leukemia cells is not only important for cancer cell survival, but also represents a vulnerability, rendering cancer cells dependent on Bcl-2 to limit IP3R activity. BIRD-2 seems to switch constitutive IP3 signaling from pro-survival into pro-death, presenting a plausible therapeutic strategy.

Septic arthritis of the temporomandibular joint after acute otitis media in a child.

Septic arthritis of the temporomandibular joint as a complication of acute otitis media is rare in the Western world. This report describes the case of a 7-year-old boy who had pain in his right ear and limited mouth opening, following the onset of acute otitis media. A contrast-enhanced computed tomography scan revealed right-sided mastoiditis and hydrops of the right temporomandibular joint, suggesting septic arthritis. Real-time PCR and microbiologic analysis identified Streptococcus pyogenes and Staphylococcus epidermidis in the joint aspirate. Treatment with arthrocentesis and antibiotics led to full recovery of temporomandibular joint function.