Are Deep Odontogenic Infections Associated With an Increased Risk for Sepsis?

BACKGROUND: Quick Sequential Organ Failure Assessment (qSOFA) is recommended to identify sepsis. Odontogenic infection (OI) can progress to sepsis, causing systematic inflammatory complications or organ failure. PURPOSE: The purpose of the study was to measure the association between OI location and risk for sepsis at admission. STUDY DESIGN, SETTING, AND SAMPLE: This retrospective cohort study included subjects treated for OI at Baylor University Medical Center in Dallas, TX, from January 9, 2019 to July 30, 2022. Subjects > 18 years old who were treated under general anesthesia were included. OI limited to periapical, vestibular, buccal, and/or canine spaces were excluded from the sample. PREDICTOR VARIABLE: The primary predictor variable was OI anatomic location (superficial or deep). Superficial OI infection includes submental, submandibular, sublingual, submasseteric, and/or superficial temporal spaces. Deep OI includes pterygomandibular, deep temporal, lateral pharyngeal, retropharyngeal, pretracheal, and/or prevertebral. MAIN OUTCOME VARIABLES: The primary outcome variable was risk for sepsis measured using a qSOFA score (0 to 3). A higher score (>0) indicates the patient has a high risk for sepsis. COVARIATES: Covariates were demographics, clinical, laboratory, and radiological findings, antibiotic route, postoperative endotracheal intubation, tracheostomy, intensive care unit, admission, and length of stay. ANALYSES: Descriptive and bivariate analyses were performed. A χ2 test was used for categorical variables. The Mann-Whitney U test was used for continuous variables. Statistical significance was P < .05. RESULTS: The sample was composed of 168 subjects with a mean age of 42.8 ± 21.5 and 69 (48.6%) subjects were male. There were 11 (6.5%) subjects with a qSOFA score > 0. The relative risk of a qSOFA > 0 for a deep OI is 5.4 times greater than for a superficial OI (136 (95.8) versus 21 (80.8%): RR (95% confidence interval): 5.4 (1.51 to 19.27), P = .004). After adjusting for age, sex, American Society of Anesthesiologists score, and involved anatomical spaces, there was a significant correlation between laterality and the number of involved anatomical spaces and qSOFA score (odd ratio = 9.13, 95% confidence interval: 2.48 to 33.55, adjusted P = <.001). CONCLUSION AND RELEVANCE: The study findings suggest that the OI location is associated with the qSOFA score >0.

Ocular Hypertelorism: Principles and Management.

Background: Ocular hypertelorism (OH) was initially considered as un-differentiated congenital cranio-facial deformity, however, I.T Jackson mentioned it as teleorbitism, considering it as increase in the inter-canthal width, inter-pupillary as well as inter-orbital distance as a result of lateralization of the orbital complex in total. Furthermore, Sailer further refined it and included the distance from the lateral orbital wall, i.e. he denoted increased inter-orbital distance along with the distance between lateral orbital walls as true hypertelorism. This condition is rare and is seen in association with midline congenital defects affecting the cranio-facial region. Classification and review of cases: The ideal time for the OH correction is usually between 5 and 8 years of age. However, the management of OH is complex, and several techniques have been described in literature for the same. Here, we describe our classification of OH, along with the evolution of the surgical aspects, the key treatment principles we follow, together with the types of the osteotomies and their indications. Furthermore, we delineate the four main principles that we have set for OH management. Results: Though the improvement in appearance is seen immediately post-surgery, however, this challenging surgery faces a multitude and common postoperative complications which have been represented in this article. The surgeon needs both the technical expertise and an inclination towards aesthetics for the execution of such procedures. Conclusion: It is preferred that the management of OH should be individualized as per the stage of the craniofacial growth and the psychosocial needs of the patient and the parents.

Immediate reconstruction of segmental mandibular defects via tissue engineering.

Ameloblastomas are benign, locally invasive odontogenic tumors that comprise approximately 1% of tumors within the jaws, with 66% located in the posterior mandible. If left untreated, these lesions can reach enormous size, resulting in considerable deformity and associated morbidity. Traditionally, defects >6 cm warranted a free-flap fibula transfer or iliac crest autogenous graft. Surgical treatment for the two presented cases included a large (>6 cm) mandibular segmental resection with immediate reconstruction via a tissue-engineering protocol that included bone morphogenetic protein (rhBMP-2), bone marrow aspirate concentrate, and cortical bone chips. Both patients had an uneventful postoperative course and healed satisfactorily. Established bone reconstruction determinants include bone volume, facial counter, esthetics, and restoration of functionality. Advances in tissue engineering provide a legitimate alternative while decreasing the risks, length of hospital stay, and postoperative morbidity.

Combined bone- and mucosa-supported 3D-printed guide for sinus slot preparation and prosthetically driven zygomatic implant placement.

The use of zygomatic implants to rehabilitate the severely atrophic maxilla has been well documented since first being introduced by Brånemark. Placement of zygomatic implants is technically complex, with catastrophic complications and numerous prosthetic challenges resulting from imprecise placement. The purpose of this report was to demonstrate a technique that allows transfer of the preoperatively planned sinus slot position to the surgical field by using cone beam computed tomography (CBCT) and an implant planning software program to fabricate a combined bone- and mucosa-supported 3D-printed surgical guide. This facilitates optimal zygomatic implant positioning and promotes favorable biomechanics with a predictable prosthetic outcome.

Orthognathic Surgery of the Mandible.

Orthognathic surgery performed in conjunction with orthodontic treatment is commonly performed to correct skeletal irregularities and realign the maxillomandibular relationship to improve occlusal function and facial esthetics. A thorough understanding of soft tissue esthetics, skeletal and occlusal relationships, and surgical techniques is required to obtain successful results. Surgical techniques have evolved greatly throughout history, as technological advances such as virtual surgical planning have become available and widely used to obtain predictable movements with minimized complications. The aim of this article is to review the orthognathic surgical procedures of the mandible, with particular attention to the indications, contraindications, preoperative assessment, surgical technique, and possible complications encountered.

Orthognathic Surgery-LeFort I Osteotomy.

Orthognathic surgery is a complex type of facial surgery that can have a profound impact on a patient's occlusal function and facial aesthetics. Close collaboration between the maxillofacial surgeon and an orthodontist is required, and the surgical team must have a strong foundation in facial analysis and firm understanding of the maxillofacial skeleton to achieve surgical success. Herein, we review the maxillary LeFort I osteotomy as it pertains to orthognathic surgery, with particular attention to the indications, contraindications, preoperative assessment, surgical technique, and possible complications encountered.

Secondary Reconstruction of the Zygomaticomaxillary Complex.

Zygomaticomaxillary (ZMC) fractures are the second most common facial fractures after nasal bone fractures. The zygoma, with its location and multiple points of articulations, lends itself to both facial structure and esthetics. Secondary ZMC deformities are complications of inadequate primary correction, delayed repair, or lack of repair. Secondary revisions of ZMC aim to correct ZMC displacement and projection and to address orbital discrepancies. Extensive correction involving significant orbital and malar defects requires zygomatic repositioning osteotomies and would greatly benefit from the utilization of virtual surgical planning, intraoperative navigation, and imaging. Minor corrections in malar projection can be corrected by onlay grafting and soft tissue augmentation and resuspension. Isolated or minor orbital corrections can be managed by autogenous or alloplastic material to restore lost orbital volume and anatomy.

Necrotizing fasciitis of the scalp stemming from odontogenic infection.

Necrotizing fasciitis is a severe, rapidly progressive infectious process characterized by rapid spread and extensive tissue destruction. This condition stems from a variety of sources, may affect any area of the body, and requires rapid diagnosis and aggressive intervention. We present a rare case of odontogenic infection progressing to acute cervicofacial necrotizing fasciitis of the scalp and neck.

A 3D-Printed Guide to Assist in Sinus Slot Preparation for the Optimization of Zygomatic Implant Axis Trajectory.

Zygomatic implants have become a predictable treatment modality for the rehabilitation of the severely atrophic maxilla. Due to differing anatomic variations, proximity to vital anatomic structures and limited intraoperative visibility, the placement of zygomatic implants can be a difficult task; compromised implant positioning may ultimately lead to postoperative surgical and prosthetic complications. The purpose of this report is to demonstrate a technique that allows for the transfer of the sinus slot position. Ultimately, this optimizes zygomatic implant axis trajectory from preoperative prosthetic planning by using cone beam computed tomography (CBCT) and 3-dimensional (3D) planning software to fabricate a stereolithographic 3D-printed surgical guide.

Dental Injuries and Management.

Traumatic dental injuries affect 1 to 3% of the population, and disproportionately affect children and adolescents. The management of these injuries incorporates the age of patients, as children between 6 and 13 years of age have a mixed dentition. This helps to preserve the vitality of teeth that may be salvaged after a traumatic event. The clinical examination of these cases involves a thorough examination of the maxilla and mandible for associated fractures and any lodged debris and dislodged teeth or tooth fragments. The objective is to rule out any accidental aspiration or displacement into the nose, sinuses, or soft tissue. After ruling out any complications, the focus is on determining the type of injury to the tooth or teeth involved. These include clinical examination for any color change in the teeth, mobility testing, and testing for pulp vitality. Radiographic evaluation using periapical, occlusal, panoramic radiographs, and cone beam computed tomography is performed to view the effect of trauma on the tooth, root, periodontal ligament, and adjoining bone. The most commonly used classification system for dental trauma is Andreasen's classification and is applied to both deciduous and permanent teeth. Managing dental trauma is based on the type of injury, such as hard tissue and pulp injuries, injuries to periodontal tissue, injuries of the supporting bone, and injuries of the gingiva and oral mucosa. Hard-tissue injuries without the involvement of the pulp typically require restoration only. Any pulp involvement may require endodontic treatment. Fractures involving the alveolar bone or luxation of the tooth require stabilization which is typically achieved with flexible splints. The most common procedures employed in managing dental injuries include root canal/endodontics, surgical tooth repositioning, and flexible splinting. Recognition and treatment of these injuries are necessary to facilitate proper healing and salvage of a patient's natural dentition, reducing future complications to patients.

Secondary Management of Midface Fractures.

Secondary reconstruction of posttraumatic facial deformities has been consistently described as one of the most challenging procedures performed. Ideal primary reconstruction cannot always be achieved, and often it is complicated by severe comminution or inadequate surgical management. It also can arise because of a lack of definitive surgical repair or excessive delay of initial treatment. Complications leading to secondary deformities can occur even when craniofacial injuries are treated by experienced surgeons. Following proper surgical principles, meticulous perioperative planning, and anticipation of potential functional and aesthetic sequelae limit many of those complications. Herein, we discuss secondary procedures in traumatic midface injuries.

Radiographic manifestations of fibroblastic osteosarcoma: A diagnostic challenge.

Osteosarcoma is the most common primary bone tumor after plasma cell neoplasms. Osteosarcoma has diverse histological features and is characterized by the presence of malignant spindle cells and pluripotent neoplastic mesenchymal cells that produce immature bone, cartilage, and fibrous tissue. Osteosarcoma most frequently develops in the extremities of long bones, but can occur in the jaw in rare cases. The clinical and biological behavior of osteosarcoma of the jaw slightly differs from that of long-bone osteosarcoma. The incidence of jaw osteosarcoma is greater in the third to fourth decades of life, whereas long-bone osteosarcoma mostly occurs in the second decade of life. Osteosarcoma of the jaw has a lower tendency to metastasize and a better prognosis than long-bone osteosarcoma. Radiographically, osteosarcoma can present as a poorly-defined lytic, sclerotic, or mixed-density lesion with periosteal bone reaction response. Multi-detector computed tomography is useful for identifying the extent of bone destruction, as well as soft tissue involvement of the lesion. The current case report presents a fibroblastic osteosarcoma involving the left hemimandible with very unusual radiographic features.

Craniofacial Injuries Seen With the Introduction of Bicycle-Share Electric Scooters in an Urban Setting.

PURPOSE: Standing electric scooters (e-scooters) are rapidly becoming popular modes of transportation in many urban areas across the United States. However, this increase in popularity has resulted in an increase in traumatic injuries associated with these modes of expedient travel. The purpose of the present study was to determine the types of craniofacial trauma directly related to e-scooter use in a major urban center (Dallas, TX). MATERIALS AND METHODS: We performed a retrospective case series and examined the medical records of the patients who had presented to the emergency department (ED) for trauma related to e-scooter use. Descriptive statistics were calculated for all variables on patient presentation, including incident notes and patient interviews, demographic information, diagnostic tests, trauma (ie, location, type, severity), treatment (ie, type, admission, outpatient referral, follow-up data), and contributing factors (ie, reported or detected alcohol use, use of protective equipment). RESULTS: A total of 90 patients (56 males, 34 females; mean age, 31.8 years) had presented with scooter-related trauma to the ED during the first 7 months of scooters after their introduction to the metropolitan area. A total of 52 admissions (58% of all admissions) involved injuries of the head and face. The patients had presented with a myriad of craniofacial trauma, ranging from abrasions, lacerations, and concussions to intracranial hemorrhage and Le Fort II and III fractures. Of the 52 craniofacial injuries, 30 (58%) were considered severe (ie, fracture, internal hemorrhage, concussion, loss of consciousness), and 22 (42%) were considered minor (ie, lacerations, contusion, abrasion, dental). Alcohol use had been involved in 18% of all scooter-related trauma admissions, and no rider had reported wearing a helmet. CONCLUSIONS: Injuries to the head and face were commonly found with e-scooter admissions in this sample, and the high prevalence of extremity injuries suggested that patients were breaking their fall during the crash. Craniofacial trauma related to e-scooter use could be significantly reduced by the wearing of a protective helmet.

Fatal deep neck infection and respiratory arrest.

Despite the wide availability of antibiotics and medical care, deep neck infections requiring hospitalization are associated with significant morbidity and mortality. Thus, early recognition and aggressive treatment are key in preventing unfavorable outcomes. We present the case of a patient who rapidly progressed from nonspecific upper respiratory symptoms to obstructive airway loss and death due to a swiftly worsening deep neck infection.

Macroglossia secondary to lisinopril-induced acute angioedema.

Presented here are two cases of acute acquired macroglossia in adults caused by angioedema resulting from a reaction to angiotensin-converting enzyme inhibitors (ACEIs). Angioedema can be caused by a variety of factors, but ACEIs are the most common precipitating factor. Symptoms such as swelling of the lips, face, tongue, and throat can lead to life-threatening airway compromise. Early management of acute angioedema and macroglossia includes antihistamines, steroids, and occasionally epinephrine, yet a small percentage of patients progress toward airway obstruction and will require intubation. Edema within the lips, face, and throat usually subsides within a week, but the tongue can remain edematous for prolonged periods if biting trauma occurs. If the patient's macroglossia does not resolve in a reasonable amount of time, a partial glossectomy may be indicated.

Craniofacial Trauma Is Associated With Significant Psychosocial Morbidity 1 Year Post-Injury.

PURPOSE: The face and head play critical roles in one's sense of self and body image; as such, facial, head, and scalp injuries and potential associated disfigurement can lead to particular difficulties in coping. This study examined the psychosocial outcomes of patients with craniofacial (CF) trauma 1 year after injury and compared these outcomes with those of other traumatically injured patients who did not sustain such injuries. It was hypothesized that participants in the CF injury group would have worse outcomes than those without CF trauma. MATERIALS AND METHODS: This prospective longitudinal study included patients at least 18 years of age admitted to the trauma service of a level I trauma center for at least 24 hours. Demographic and injury-related variables were collected. CF injury was determined by International Classification of Diseases, Ninth Revision codes. Outcomes were measured at baseline and at 12 months and included depression, post-traumatic stress disorder (PTSD), alcohol use, and pain severity. Paired t tests and logistic regression were used for analysis. RESULTS: Fifteen percent (n = 35) of the study sample (N = 230) had CF injuries. Those with CF injuries had lower income, higher injury severity, and higher intensive care unit admission rates. The CF and non-CF trauma groups did not differ in rates of depression or PTSD at either time point. However, participants with CF trauma had higher odds of risky alcohol use than those without CF trauma at baseline and lower odds of a higher pain severity score at baseline and 12 months. CONCLUSIONS: The groups did not differ in depression and PTSD. However, rates of depression, PTSD, alcohol use, and physical pain were higher than expected for the 2 groups. Given the high rate of psychological morbidity found after CF trauma, patients with these injuries should be screened for symptoms soon after injury and provided with resources for treatment.

A comparative study of two different techniques for complete bilateral cleft lip repair using two-dimensional photographic analysis.

BACKGROUND: The aim of this study was to compare the clinical outcomes of two techniques to repair complete bilateral cleft lip by using indirect two-dimensional photographic analysis. METHODS: One hundred eight bilateral cleft patients were included in this study, 54 patients operated on with the Millard technique and 54 patients operated on with the Afroze technique. Each group of patients was further separated into two subgroups containing symmetrical and asymmetrical cleft lips. All patients were photographed preoperatively and 4 years postoperatively in frontal and submentovertical views in a reproducible way. Eight measurements were performed on the photographs. From these measurements, seven ratios were calculated to compare the two techniques. RESULTS: The outcomes of the interobserver and intraobserver measurements were analyzed using the Pearson correlation test. There was a statistically significant reliability in the intraobserver and interobserver ratios. Analysis of the ratios was performed using the independent samples t test (5 percent level of significance). The authors found that the Afroze technique was better than the Millard technique in six of the seven parameters for symmetrical clefts and in four of the seven parameters for asymmetrical clefts; however, there was no statistically significant difference seen between the two techniques. CONCLUSIONS: The Afroze technique seems to have good clinical outcomes on bilateral cleft lip patients, but more research and long-term follow-up are needed to determine the full outcome of the technique in various parameters.

Developing and standardizing a center to treat cleft and craniofacial anomalies in a developing country like India.

The range of facial deformities is enormous. All produce some degree of disfigurement and result in the impairment of function to some degree, sometimes even to the point of incompatibility with life. Congenital facial defects in India are associated with considerable superstition, social rejection, and failure to integrate into society.In India, cleft defects occur in 1 in 500 births. Congenital facial defects are a pressing problem in India owing to the limited resources to treat such patients. Poverty is a major factor for parents of such children to get appropriate treatment.Setting up an institute to treat children with cleft and craniofacial deformities in India presents problems with financing treatment for poor patients, procuring the right infrastructure, and employing well-trained human resources.The authors have set up such an institute in Hyderabad in the southern state of Andhra Pradesh in India. The logistics of setting up such a facility in a developing country and the future of funding for cleft treatment are important factors to consider while establishing a center for patients with cleft and craniofacial anomalies.The aim of setting up such centers was to provide quality comprehensive treatment for patients from all sections of society with cleft and craniofacial anomalies.