Predictors of Intraoperative Difficulty and Postoperative Examination Abnormalities in 164 Orbital Operations.

BACKGROUND: Although orbital fractures are common, prediction of outcomes in orbital surgery can be quite challenging. PURPOSE: We aim to identify predictors of intraoperative difficulty, operating time, and postoperative examination abnormalities in subjects undergoing post-traumatic orbital reconstructions. STUDY DESIGN, SETTING, AND SAMPLE: This is a retrospective cohort study of all consecutive orbital operations performed at a private, Level 1 trauma center in Portland, Oregon, USA over an 82-month period. All subjects that underwent exploration of the internal orbit for traumatic indications during the study period were included in the cohort. PREDICTOR VARIABLES: Four plating styles, surgical approach (transorbital vs transantral), days from injury to first surgery, fracture size (approximated as a rectangle using linear measurements from computed tomography scans), anteroposterior fracture position, and medial wall involvement were examined. OUTCOME VARIABLES: The primary outcome variable was intraoperative difficulty (defined as requiring revision after intraoperative imaging or return to the operating room). Secondary outcome variables included operating time and postoperative examination abnormalities. COVARIATES: Age and sex were included. ANALYSES: χ2 and Regression analyses were performed using a significance level of P < .05. RESULTS: One hundred and sixty four orbital operations were performed (90 isolated injuries and 74 combined orbital/midface injuries) on 155 subjects (73% male, mean age 39.8 years, standard deviation 16.7). In subjects with isolated orbital fractures, medial wall involvement was associated with intraoperative difficulty (P = .01). When using a transantral approach, intraoperative difficulty was more likely in more anterior fractures (P = .02). Plating style was associated with operating time (P = .03), with median times from 81 to 105 minutes (range 21 to 248 minutes). Postoperative examination abnormalities were more likely in the transorbital approach group (P = .01). Neither days to first surgery nor intraoperative difficulty were associated with postoperative examination abnormalities. Postoperative eyelid changes were seen in 13.6% of transorbital approaches and 0% of transantral approaches. Correction of gaze restriction and enophthalmos were more likely than correction of diplopia (P < .01). CONCLUSIONS AND RELEVANCE: Medial wall involvement is associated with intraoperative difficulty in orbital surgery. Anteriorly positioned fractures are better treated transorbitally, while posterior fractures may be amenable to transantral repair, thus avoiding risk of lower eyelid changes.

Medicare coverage patterns favor non-invasive and minimally-invasive treatments of knee osteoarthritis compared to temporomandibular joint osteoarthritis.

OBJECTIVE: To compare Medicare coverage patterns for treatments of knee osteoarthritis (OA) to those of temporomandibular joint (TMJ) OA. METHODS: The International Classification of Diseases (ICD)-10 codes were used to identify knee OA, TMJ OA, and related diagnoses. The AAPC Coder was utilized to search for Medicare insurance coverage by state/district for the indicated CPT codes. The coverage for treatments of TMJ OA and knee OA was analyzed by Fisher's exact test. RESULTS: There was a statistically significant difference in the coverage of physical therapy, massage therapy, and arthrocentesis for TMJ OA and knee OA. The current study showed that arthrocentesis was covered 100% in all states/districts for knee OA and 0% for TMJ OA. CONCLUSION: Medicare covers TMJ OA treatments to a lesser degree than knee treatments. Documentation of this discrepancy serves as an important first step in advocating for improvements in coverage, and subsequently, in access to care.

A descriptive analysis of predoctoral surgical requirements in US dental schools in 2020.

OBJECTIVES: This study aims to describe surgical graduation requirements in US dental schools in 2020, including changes made due to the COVID-19 pandemic. METHODS: Representatives of Commission on Dental Accreditation-approved predoctoral dental programs in the US (n = 66) received a 13-item questionnaire about operative and observational surgical requirements. Responses were assigned values to tabulate a surgical score (zero- to eight-point scale) as a proxy for required surgical experience, and statistical analyses were performed to explore for predictors. RESULTS: Surveys were returned by 97% (64/66) of programs with complete data from 62.5% of responding institutions. In periodontics, 6.8% of programs require students to perform periodontal surgery, 63.8% to assist, and none require a competency assessment in periodontal surgery. In oral and maxillofacial surgery, 23.3% of programs have numerical requirements in performance of surgical extractions, 35% require an operating room experience, and 51.9% have a competency assessment involving a surgical procedure. Modifications to surgical and nonsurgical graduation requirements due to COVID-19 were reported by 51.6% and 52.5% of programs, respectively. The mean surgical score was 1.73 ± 1.2 (range = 0-4) of eight possible points. This was not predicted by class size or the presence of postgraduate surgical programs. The presence of postgraduate surgical programs roughly doubled the likelihood of requiring an observational experience in surgery. CONCLUSIONS: As of 2020, US dental programs require a small fraction of surgical experiences available to students. Class size is not a predictor of required surgical experience. The presence of postgraduate surgical programs increased the likelihood of required observational experiences.

An Endonasal Incision Adds a Second Vector of Manipulation During Percutaneous Reduction of Fractures Involving the Frontonasal Region.

STUDY DESIGN: A case report. OBJECTIVE: To describe a modification of percutaneous reduction of frontal sinus and/or naso-orbito-ethmoid (NOE) fractures, adding an endonasal intercartilaginous incision to provide a second vector of manipulation. METHODS: Case report with particular attention paid to surgical technique, followed by a brief review of relevant literature. RESULTS: Technique: A Carroll-Girard screw is used to engage the thickest part of the anterior wall of the frontal bone through a stab incision just superior to the frontonasal junction. An endonasal intercartilaginous incision is then made and a Cottle elevator is introduced to manipulate the fracture from the inferior aspect of the frontonasal junction. The percutaneous screw and the endonasal elevator provide perpendicular vectors for manipulation, thereby improving ability to reduce fractures when percutaneous traction alone is not successful. The technique is described here in a patient with anterior table frontal sinus fractures combined with posteriorly displaced Markowitz type 1 NOE fractures. CONCLUSION: While percutaneous reduction of frontal sinus fractures has been previously described, this report adds a subtle but important modification both in indication and technique for optimizing reduction while maintaining surgical simplicity and minimizing morbidity.

Orbital Volume Correction in Orbital Floor Fractures: A Comparison of Transorbital and Transantral Techniques.

PURPOSE: We compared the accuracy of orbital volume correction between the transorbital and transantral reconstructive techniques. MATERIALS AND METHODS: A retrospective cohort study was performed of patients who had undergone repair of isolated, unilateral orbital floor blowout fractures at Legacy Emanuel Hospital from 2013 to 2018. A total of 21 patients were identified and included in the predictor variable cohorts of the transorbital versus transantral repair technique. The outcome variable of orbital volume correction was evaluated by comparing the volume of the postoperative repaired orbits with that of the contralateral noninjured orbits. Additional ordinal variables analyzed included the preoperative orbital defect size and analysis of the transantral cohort stratified by the plating technique used. Data were assessed using analysis of variance and paired t tests. RESULTS: A transantral approach was used for orbital repair in 9 patients. In these patients, the postoperative orbital volume in the injured orbit was 2.69% greater than that in the uninjured orbit. The 12 patients who had undergone transantral repair had a postoperative orbital volume in the injured orbit that was 0.56% smaller than that of the uninjured orbit (P = .033). Division of the transantral cohort into 2 different plating techniques identified a less than 1% difference in mean orbital volume correction between the 2 techniques (P = .104). The average defect volume before transorbital repair was 4.87 cm3 compared with 5.22 cm3 for transantral repair (P = .907). CONCLUSIONS: The results from the present study have shown that the accuracy of orbital volume correction using the transantral approach will be comparable to that of the transorbital approach, as shown by a small, but statistically significant, increased accuracy in the volume correction with the transantral approach. Additional investigation to establish clinical correlations with these findings should be conducted.

Four Practical Reconstructive Techniques Using the Transantral Approach to the Orbital Floor Without the Need for an Endoscope.

Fractures of the orbital floor have traditionally been treated through transorbital approaches. Transconjunctival approaches risk entropion, whereas transcutaneous approaches risk ectropion or hypertrophic scarring. The intraoral transantral approach to the orbital floor has the advantage of minimizing the risk of any eyelid changes while providing appropriate access to reduce the herniated orbital contents and restore orbital volume. This article describes 4 plating methods for reconstructing a fractured orbital floor using a transantral approach. Many prior descriptions of transantral treatment of the orbital floor have relied heavily on the use of an endoscope. This article describes an osteotomy technique that does not require an endoscope but requires only a high-quality headlight for visualization.

Unmet dental needs and barriers to care for children with significant special health care needs.

PURPOSE: The purpose of this study was to conduct the first known large scale survey of parents of children with special health care needs (CSHCN) to determine their child's: oral health status; access to dental care; perceived barriers (environmental/system and nonenvironmental/family); and oral health quality of life, accounting for each child's medical diagnosis and severity of diagnosis. METHODS: A 72-item survey was sent to 3760 families of CSHCN throughout urban and rural Massachusetts. RESULTS: The study yielded 1,128 completed surveys. More than 90% of the children had seen a dentist within the past year; 66% saw a pediatric dentist, and 21% needed intense behavioral interventions. Although most families had high education levels, private dental insurance, and above average incomes, 20% of CSHCN had an unmet dental need. Children with craniofacial anomalies had twice as many unmet needs and children with cystic fibrosis had fewer unmet needs. Children with cerebral palsy, autism, developmental delay, and Down syndrome had more aversions to dental treatment, more treatment complications posed by their medical conditions, and more difficulty finding a dentist willing to provide care. Children with cystic fibrosis, metabolic disorders, or hemophilia encountered fewer barriers to care. CONCLUSIONS: The data paint a picture of high unmet dental needs with subpopulations of children with special health care needs who are more at risk for system barriers and internal family barriers to care based on their medical diagnoses.