Non-surgical management of paediatric and adolescent mandibular condyles: A retrospective review of 49 consecutive cases treated at a tertiary referral centre.

INTRODUCTION: Mandibular fractures account for over 50% of all facial fractures in children, with the majority of these occurring at the condyle. There is currently no consensus on the management of mandibular condyle fractures in the paediatric population. Treatment options range from conservative management, with or without maxillomandibular fixation (MMF) and physiotherapy, to open reduction and internal fixation (ORIF). METHODS: This was a retrospective review of all patients who attended Alder Hey Children's Hospital with fractured condyle(s) between the years 2000 and 2015. All patients were managed non-surgically and included those managed conservatively and/or with MMF. The following variables were recorded: age, sex, mechanism of injury, concomitant mandibular fractures, imaging, SORG classification, complications and follow-up intervals. The following exclusion criteria applied: patients who underwent open reduction internal fixation of their condylar fracture and patients aged 16 years or over. RESULTS: Forty-nine patients (38 male, 11 female) underwent non-surgical management of condylar fractures during the 15-year study period. The mean age at time of injury was 12 years (range 2-15 years). The etiology of fractures comprised mechanical falls (n = 22), assault (n = 14), sport (n = 5), road traffic accident (n = 3), epileptic fit (n = 1), and unknown mechanism (n = 4). The mean length of hospital stay was 3 days, ranging from 0 to 14 days. Thirty-seven patients had a concomitant mandibular fracture and 12 had an isolated unilateral condylar fracture. Follow-up intervals ranged from 1 to 133 weeks, with a median length of 12 weeks. Fifteen patients underwent MMF, while 34 had soft diet and physiotherapy only. Ninety-two per cent of patients had no complications. No patient had failure of treatment requiring a return to theatre and/or ORIF. Occlusion, interincisal distance, asymmetry and TMJ symptoms were examined in 43/49 patients who attended their postoperative appointments. Four patients (8%) had complications in the postoperative period, namely: lateral open bite (n = 2), deviation to the affected side on wide opening (n = 1), and non-specific TMJ dysfunction (n = 1). None of these patients presented with any subjective symptoms and none developed asymmetry or needed any further surgical intervention. CONCLUSION: Paediatric and adolescent mandibular condyle fractures can be safely and predictably managed using conservative methods. In our, albeit small, study cohort all patients were managed conservatively, and all had a satisfactory outcome with no requirement for further operative intervention.

Early Extended Midline Strip Craniectomy for Sagittal Synostosis.

BACKGROUND: Isolated sagittal synostosis is the most common form of nonsyndromic craniosynostosis. The surgical management of this condition ranges from strip craniectomy to total cranial vault remodeling. In our unit, passive correction of sagittal synostosis utilizing open extended midline strip craniectomy with bilateral micro-barrel staving is performed before 22 weeks corrected age. The aim of this prospective study is to identify the effectiveness and morbidity associated with this technique. PATIENTS AND METHODS: Nonsyndromic patients who underwent OMEC at a tertiaryreferral-center (Alder Hey Children's Hospital, Liverpool, UK) over a 3-year period (2014-2016) were included. In particular, we looked at pre- and postoperative cranial index (CI), as well as other secondary outcomes such as rates of transfusion and reoperation. RESULTS: A total of 44 patients (12 female, 32 male) met the inclusion criteria. Median age at operation was 132 (range 99-171) days. Median operative time was 117 (range 89-171) minutes. Twenty-four patients underwent a blood transfusion. Median pre-op CI was 66 (range 61-74.7)%. The first post-op CI, taken a median of 56 (range 12-107) days postoperatively, was 78 (range 73-87)%. No patients required reoperation. There were no perioperative deaths. CONCLUSION: Early open extended midline strip craniectomy with bilateral micro-barrel staving for correction of isolated nonsyndromic sagittal synostosis is a safe and effective technique, associated with minimal morbidity, producing sustained satisfactory head shape morphology on short to medium-term follow-up.

Head and neck reconstruction with free flaps based on the thoracodorsal system.

The advent or micro-vascular free tissue transfer has facilitated the reconstruction of increasingly complex head and neck defects. There are multiple donor sites available, each with its' own advantages and disadvantages. However, the subscapular system, including the thoracodorsal system, provides the widest array of soft tissue and osseous flaps, as well as chimeric options. Its advantages include a long pedicle, independently mobile tissue components, relative sparing from atherosclerosis, and minimal donor site morbidity. The soft tissue flaps available from the thoracodorsal system include the Latissimus Dorsi, and Thoracodorsal Artery Perforator flaps, while the Tip of Scapula provides the osseous component. This review paper outlines the anatomical basis for these flaps, as well as describing their utility in head and neck reconstruction.

Sports-Related Maxillofacial Injuries.

BACKGROUND: Sports-related maxillofacial injuries contribute a significant proportion of the workload in a maxillofacial unit. The aim of this study was to identify the incidence of maxillofacial sports-related injuries, treatments required, and assess the impact of the injury on future sport participation. METHOD: A retrospective review was carried out on all maxillofacial trauma referrals from September 1, 2009 to August 31, 2010. Patient records were reviewed and the following variables were recorded: age, sex, sport involved, injury sustained, mechanism of injury, treatment, subsequent participation, and interval before return to sport. RESULTS: The study population included 162 patients with sports-related facial injuries. The most common sporting injuries were as follows: Gaelic football 35.3% (N = 57), soccer 22.3% (N = 36), rugby 12.4% (N = 20), and equine sports 12.4% (N = 20). The most common injury sustained was zygomatic complex fracture 36.4% (N = 59). Mandibular fracture occurred in 20% (N = 33), orbit fracture in 14.2% (N = 23), and nasal bone fracture in 12.3% (N = 20). The most common mechanism of injury was from a clash of heads (23.4%) followed by an elbow to the face (17.2%). The majority of patients (84%) resumed participation in their chosen sport at mean interval of 7.3 weeks (range 1-18 weeks). CONCLUSIONS: This study identified a significant number of sporting facial injuries, which presented over 1 year. In total, 113 patients underwent a surgical procedure for the management of their injuries. This study highlights the need to educate all players regarding use of personal protective equipment and adherence to the rules of sports.

Aggressive giant cell lesion of the jaws: a review of management options and report of a mandibular lesion treated with denosumab.

Giant cell lesions (GCLs), previously referred to as giant cell granulomas, are benign tumors of the jaws of unknown etiology. Surgical management of aggressive GCLs is challenging, as these lesions demonstrate a tendency to recur following surgical removal. In addition, surgical treatment can be associated with significant morbidity. In an attempt to reduce both the extent of morbidity and the recurrence rate following surgery, a number of pharmacologic therapies have been advocated on the basis of assumptions about the predominant cell types and receptors, for the management of these lesions. This report describes the use of denosumab, an agent originally used for its anti-resorptive effects, in the management of an aggressive GCL of the mandible in an older patient, who was unsuitable for extensive surgery and in whom treatment with intralesional triamcinolone had proved unsuccessful. Denosumab may be a viable alternative or adjunct to surgery in the management of GCLs of the jaws.

Reconstruction of orbital floor blow-out fractures with autogenous iliac crest bone: a retrospective study including maxillofacial and ophthalmology perspectives.

This is a 10-year retrospective study of patients with an isolated unilateral orbital floor fracture reconstructed with an autogenous iliac crest bone graft. The following inclusion criteria applied: isolated orbital floor fracture without involvement of the orbital rim or other craniofacial injuries, pre-/post-operative ophthalmological/orthoptic follow-up, pre-operative CT. Variables recorded were patient age and gender, aetiology of injury, time to surgery, follow-up period, surgical morbidity, diplopia pre- and post-operatively (Hess test), eyelid position, visual acuity, and the presence of en-/or exophthalmos (Hertel exophthalmometer). Twenty patients met the inclusion criteria. The mean age was 29 years. The mean follow up period was 26 months. No patient experienced significant donor site morbidity. There were no episodes of post-operative infection or graft extrusion. Three patients had diplopia in extremes of vision post-operatively, but no interference with activities of daily living. One patient had post-operative enophthalmos. Isolated orbital blow-out fractures may be safely and predictably reconstructed using autogenous iliac crest bone. The rate of complications in the group of patients studied was low. The value of pre- and post-operative ophthalmology consultation cannot be underestimated, and should be considered the standard of care in all patients with orbitozygomatic fractures, in particular those with blow-out fractures.

New oral anticoagulants and their implications for dental patients.

Anticoagulation therapy is used in several conditions to prevent or treat thromboembolism. Over the last 40 years, warfarin has been the oral anticoagulant of choice and has been considered the mainstay of treatment. However, its use is limited by a narrow therapeutic index and complex pharmacodynamics, necessitating regular monitoring and dose adjustments. Recently, two new oral anticoagulants--dabigatran etexilate (a direct thrombin inhibitor) and rivaroxiban (a factor Xa inhibitor)--have been approved for use in North America and Europe. Unlike warfarin, dabigatran and rivaroxiban are relatively small molecules that work as anticoagulants by targeting specific single steps of the coagulation cascade. Their advantages, relative to warfarin, include: predictable pharmacokinetics; limited food and drug interactions; rapid onset of action; and, short half-life. They require no monitoring. However, they lack a specific reversal agent. The number of patients taking dabigatran and rivaroxaban is increasing. Therefore, it is inevitable that dentists will be required to perform invasive procedures on this cohort of patients. This paper outlines the various properties of the new oral anticoagulants and the most recent guidelines regarding the management of these dental patients taking these medications.

Management of large erupting complex odontoma in maxilla.

We present the unusual case of a large complex odontoma erupting in the maxilla. Odontomas are benign developmental tumours of odontogenic origin. They are characterized by slow growth and nonaggressive behaviour. Complex odontomas, which erupt, are rare. They are usually asymptomatic and are identified on routine radiograph but may present with erosion into the oral cavity with subsequent cellulitis and facial asymmetry. This present paper describes the presentation and management of an erupting complex odontoma, occupying the maxillary sinus with extension to the infraorbital rim. We also discuss various surgical approaches used to access this anatomic area.