Utility of Routine Computed Tomography Angiogram Screening for Blunt Carotid Injury in Isolated Mandible Fractures.

PURPOSE: Determine the incidence of blunt carotid injury (BCAI) in the blunt trauma induced isolated mandible fracture population and determine the utility of computed tomographic angiography (CTA) screening for BCAI in this population. METHODS: A retrospective data review was performed on patients presenting to Boston Medical Center from January 2008 to January 2019 with a diagnosis of mandible fracture. Population selected utilizing ICD-9 and ICD-10 diagnosis codes for mandible fracture and BCAI. Excluded populations were pediatric (less than 18 years) and penetrating carotid injuries. RESULTS: A total of 1,508 mandible fractures were identified, with 73% (n = 1,103) being isolated injuries. Five BCAIs were identified, and of these, 1 was associated with an isolated mandible fracture (incidence <0.01%). One of 110 isolated mandible fractures screened for BCAI with the use of CTA was positive (incidence 0.9%). CONCLUSIONS: BCAI is a rare finding in isolated mandible fractures. The inclusion of this population as an independent risk factor for BCAI should be questioned. Routine screening with CTA is not warranted.

Medicare Reimbursement Trends for Hospital-Based Oral Maxillofacial Surgery Procedures: 2003 to 2020.

PURPOSE: To evaluate recent trends in Medicare reimbursement rates for common hospital-based oral-maxillofacial surgery procedures. METHODS: Physician Fee Schedule Look-Up Tool by the Centers for Medicare and Medicaid Services was searched for reimbursement rates for the 20 most performed oral-maxillofacial surgery procedures between 2003 and 2020. Total percent change, annual percent change, and compound annual growth rate (CAGR) were calculated using the adjusted reimbursement rates over the study period. Annual changes in reimbursement rates before and after 2016 were compared. RESULTS: After adjusting for inflation, average reimbursement rates for procedures decreased by 13.4%. Annual percent change and CAGR were -0.79 and -0.88%, respectively. Annual reimbursements decreased more between 2016 to 2020 (-1.83%,) than from 2003 to 2016 (-0.49%; P value = .003). CONCLUSION: Inflation-adjusted Medicare reimbursement rates for oral-maxillofacial surgery procedures have decreased from 2003 to 2020. The rate of reimbursement decreases has accelerated in recent years.

Should Multilevel Phase I Surgical Therapy be Recommended as Treatment for Moderate Obstructive Sleep Apnea due to Oropharyngeal and Hypopharyngeal Obstruction?

PURPOSE: The purpose of this study was to evaluate the efficacy of multilevel phase I surgery for the treatment of moderate obstructive sleep apnea (OSA) in retrognathic patients with oropharyngeal and hypopharyngeal obstruction. MATERIALS AND METHODS: This was a 10-year retrospective cohort study of patients treated by a single surgeon at the Boston University Medical Center. From 2000 to 2010, retrognathic patients with moderate OSA and verified palatal and tongue base obstruction were treated with multilevel phase I surgery that included uvulopalatopharyngoplasty, hyoid suspension, and genioglossus advancement. All patients were evaluated clinically and received polysomnographic studies at three time points: preoperatively (T1), between 6 and 12 months postoperatively (T2), and a minimum of 24 months postoperatively (T3). RESULTS: Twenty-five subjects composed the final study sample. At T2, 11 patients (44.0%) experienced a complete response, 13 (52.0%) experienced a partial response, and 1 (4.0%) experienced no response. Although phase I surgery was associated with significant changes in AHI (F(2,48) = 119.3; P < .01) throughout the follow-up period, only one patient at T3 (4.0%) met the criteria for a complete response. The remaining patients were divided evenly between partial response (48.0%) and treatment failure (48.0%), of whom 4 (16.0%) patients had worsening of their obstruction. Thirteen of these patients subsequently elected to undergo maxillomandibular advancement, while 11 elected to continue using continuous positive airway pressure. CONCLUSIONS: Although phase I surgery was associated with AHI changes, this reduction was not sufficient to produce a long-term treatment response in over half of our patients. Treatment response was worse after 2 years than at 6 to 12 months. Patients with moderate OSA should understand that multilevel phase I surgery has a greater chance of failure than success and that transient improvements may not be durable.

Opioid Prescribing Patterns Among Oral and Maxillofacial Surgeons: A Regional Survey-Based Study.

PURPOSE: We sought to obtain baseline statistics regarding the amount of opioid tablets prescribed by oral and maxillofacial surgeons (OMSs) in the New England area after office-based procedures and to identify factors that might be predictors of their prescription patterns. MATERIALS AND METHODS: An anonymous online survey was e-mailed to practicing OMSs in the New England area. The survey explored the quantity of opioid medications prescribed for various procedures, how opioid precautions were given, practitioners' attitude toward opioid dependency, and whether certain surgeon- or patient-related factors influenced prescription behavior. Statistical analyses were used to categorize the OMSs according to their prescription patterns and to identify the most common factors affecting their decision to prescribe opioids. RESULTS: Of 315 OMSs, 151 (43%) responded to the survey. Our analyses were of complete data obtained from 118 respondents. For procedures, such as extraction of 7 or more teeth, the placement of 4 or more implants, office-based sinus surgery, cortical block grafts, and removal of third molar teeth, respondents indicated they typically prescribed 8 to 12 opioid tablets. For all other procedures, they typically never or rarely prescribed opioid tablets. The respondents were grouped into low-, medium-, and high-quantity opioid prescribers. Regardless of their grouping status, the respondents showed general agreement regarding their roles in reducing opioid prescription-related issues. No group differences were found in terms of the demographic variables. Relative to the factors predicting increased prescribing habits, the results suggested that OMSs working either exclusively or primarily in academic settings tended to prescribe fewer opioid tablets than those working primarily in the private setting (ß = -2.73; P < .001). Additionally, 109 respondents (92.4%) reported that OMSs could play a role in decreasing opioid dependency. CONCLUSIONS: Most practicing OMSs in the New England area prescribed opioids after office-based surgery and are cognizant of the risks of opioid medications.

Considerations for Oral and Maxillofacial Surgeons in COVID-19 Era: Can We Sustain the Solutions to Keep Our Patients and Healthcare Personnel Safe?

Several uncertainties exist regarding how we will conduct our clinical, didactic, business, and social activities as the coronavirus disease 2019 (COVID-19) global pandemic abates and social distancing guidelines are relaxed. We anticipate changes in how we interact with our patients and other providers, how patient workflow is designed, the methods used to conduct our teaching sessions, and how we perform procedures in different clinical settings. The objective of the present report is to review some of the changes to consider in the clinical and academic oral and maxillofacial surgery workflow and, allow for a smoother transition, with less risk to our patients and healthcare personnel. New infection control policies should be strictly enforced and monitored in all clinical and nonclinical settings, with an overall goal to decrease the risk of exposure and transmission. Screening for COVID-19 symptoms, testing when indicated, and establishing the epidemiologic linkage will be crucial to containing and preventing new COVID-19 cases until a vaccine or an alternate solution is available. Additionally, the shortage of essential supplies such as drugs and personal protective equipment, the design and ventilation of workspaces and waiting areas, the increase in overhead costs, and the possible absence of staff, if quarantine is necessary, must be considered. This shift in our workflow and patient care paths will likely continue in the short-term at least through 2021 or the next 12 to 24 months. Thus, we must prioritize surgery, balancing patient preferences and healthcare personnel risks. We have an opportunity now to make changes and embrace telemedicine and other collaborative virtual platforms for teaching and clinical care. It is crucial that we maintain COVID-19 awareness, proper surveillance in our microenvironments, good clinical judgment, and ethical values to continue to deliver high-quality, economical, and accessible patient care.

Outpatient Anesthesia Morbidity and Mortality Experience Among Massachusetts Oral and Maxillofacial Surgeons.

PURPOSE: The purpose of this retrospective study was to document the prevalence of different complications and the mortality rate for outpatient procedures performed under anesthesia by oral and maxillofacial surgeons in the Commonwealth of Massachusetts. MATERIALS AND METHODS: A mailed questionnaire was filled out by active members of the Massachusetts Society of Oral & Maxillofacial Surgeons who practiced using the single-operator-anesthetist model. Morbidity and mortality information was acquired for calendar years 2015 and 2016. RESULTS: The findings of this study were consistent with those of previous publications on the same topic. No office deaths occurred, and the mortality rate was 0 of 431,680 patient visits. The prevalence of other anesthesia-related complications was low. CONCLUSIONS: On the basis of the results of our study, we can conclude that the office-based team model used by oral and maxillofacial surgeons in Massachusetts for the delivery of outpatient anesthesia is safe with a low complication rate.

Postoperative Pain and Opioid Analgesic Requirements After Orthognathic Surgery.

PURPOSE: The purpose of this study was to determine the effect of individual characteristics, such as age, gender, and type of surgery, on postoperative pain intensity and opioid analgesic consumption after orthognathic surgery. PATIENTS AND METHODS: This prospective observational study was conducted at a single academic medical center during a 12-month period from 2015 to 2016. Thirty of 125 patients 18 to 65 years of age who had American Society of Anesthesiologists status I and II and were admitted to the hospital after orthognathic surgery were recruited. The main outcome variable was opioid analgesic consumption measured in morphine milligram equivalents (MME) during the patients' hospital stay. Secondary outcome variables were postoperative pain intensity measured using the numeric rating scale (0 to 10) and length of hospital stay. Data on age, gender, type of surgery, postoperative pain intensity, and opioid and nonopioid analgesic consumption for each 24-hour period during hospitalization were collected. The analgesic regimen consisted of oxycodone, hydromorphone, and acetaminophen. Differences in postoperative pain and opioid requirements between men and women, older and younger, and 1- and 2-jaw surgery were assessed using unpaired Student t test for statistical analysis. A P value less than .05 was considered statistically significant. RESULTS: Thirty patients (14 men, 16 women) with an average age of 26.3 years (18 to 50 yr) were admitted to the hospital for an average of 61 hours (24 to 170 hours) after orthognathic surgery. Twenty-three of 30 patients (77%) had bimaxillary surgery. The average postoperative pain score was 6.0 (2 to 8.5) on a scale of 0 to 10 and average opioid consumption was 106 MME (range, 0 to 407 MME). Women reported more postoperative pain (6.3 vs 5.3) and consumed more opioid analgesic than men (131 vs 78 MME). Patients younger than 25 years required 112 MME of opioid compared with 98 MME for those older than 25 years, although the 2 age groups reported similar pain scores. Patients who had 2-jaw surgery and mandibular (1-jaw) surgery reported more pain and required more opioid analgesics than those who had only maxillary surgery. CONCLUSION: Based on these study results, there appears to be a trend for increased opioid analgesic requirement in women and younger patients during the immediate postoperative period after orthognathic surgery.

Temporomandibular Joint Reconstruction in Patients With Autoimmune/Connective Tissue Disease.

PURPOSE: To evaluate clinical outcomes in patients with autoimmune or connective tissue (CT) disease undergoing temporomandibular joint (TMJ) reconstruction. MATERIALS AND METHODS: Patients were divided into 2 groups based on type of TMJ reconstruction. Patients in group 1 (n = 9) underwent autogenous reconstruction and had a diagnosis of rheumatoid arthritis (5), lupus arthritis (1), and psoriatic arthritis (3). Patients in group 2 (n = 2l) had alloplastic reconstruction with a patient-fitted total joint prosthesis (TMJ Concepts, Ventura, CA) and had a diagnosis of rheumatoid arthritis (15), lupus (3), and psoriatic arthritis (3). Standardized clinical and radiographic examinations were performed before surgery, immediately after surgery, and at longest follow-up after surgery (T3). RESULTS: Group l showed no meaningful improvement in maximal opening without pain, a decrease in lateral excursions, minimal decrease in TMJ pain, and a 32% relapse of chin projection at point B at T3. Average postsurgery follow-up time was 58 months. Postsurgical ankylosis was seen in 22% of patients. In contrast, group 2 showed a statistically meaningful decrease in subjective TMJ pain and lateral excursive movements and improvement in jaw function, diet, maximal incisal opening without pain, and only 5% showed a relapse at point B at T3. Average postsurgical follow-up in this group was 78 months. CONCLUSIONS: Improved treatment outcomes were obtained with alloplastic TMJ total joint reconstruction compared with autogenous TMJ reconstruction in patients with autoimmune or CT disease.

Temporomandibular Joint Condylar Osteochondroma: Complete Condylectomy and Joint Replacement Versus Low Condylectomy and Joint Preservation.

PURPOSE: Recommended treatment for patients with osteochondromas of the mandibular condyle is to perform complete condylectomy with joint replacement. Low condylectomy with joint preservation has recently been proposed as a treatment option. This study compared the outcomes of these treatment options in patients with condylar osteochondromas. PATIENTS AND METHODS: Patients were divided into 2 groups: patients who underwent complete condylectomy and joint replacement (group A, n = 13) and patients who underwent low condylectomy and joint preservation (group B, n = 8). To optimize occlusion, function, and esthetics, maxillary and mandibular orthognathic procedures were performed as necessary to re-establish vertical ramus height. Outcomes were measured clinically and radiographically. RESULTS: The 2 groups showed significant clinical improvement (P < .05), with no tumor recurrence. Group A had increased operating room (OR) time and donor-site complications in those who received autogenous joint reconstruction compared with alloplastic joint replacement. Group B had a shorter OR duration with quicker postoperative recovery. Orthognathic procedures were stable in all cases. CONCLUSIONS: Complete and low condylectomies are viable options for the surgical management of osteochondromas of the mandibular condyle. If temporomandibular joint (TMJ) reconstruction is required, patient-fitted TMJ replacements provide similar clinical outcomes as autogenous reconstruction, but have the advantages of eliminating donor-site morbidity and decreasing operating time.

Is Alloplastic Temporomandibular Joint Reconstruction a Viable Option in the Surgical Management of Adult Patients With Idiopathic Condylar Resorption?

PURPOSE: Idiopathic condylar resorption (ICR) presents diagnostic and therapeutic challenges to practitioners because of the rarity of the condition, progressive deformity, and simultaneous involvement of skeletal, occlusal, and articular disorders. The objective of this study was to report clinical outcomes after prosthetic replacement of the temporomandibular joint (TMJ) for the management of ICR. PATIENTS AND METHODS: A retrospective analysis of patients with ICR managed by bilateral total TMJ replacement and concomitant mandibular advancement with or without maxillary surgery was performed using data gathered from medical records. The primary treatment outcomes of interest were 1) correction of anterior open bite malocclusion, 2) mandibular advancement, and 3) increase in posterior facial height. Secondary outcomes included subjective assessment of pain, dietary restrictions, and functional disability and objective evaluations of TMJ sounds, occlusal relation, mandibular range of motion, cranial nerve VII injury, and objectionable scarring. Radiographs were used to measure surgical change and relapse. RESULTS: Twenty-one patients met the inclusion criteria for this retrospective study. The average patient age was 25.6 years (range, 22 to 32 yr) and mean follow-up was 6.2 years (range, 5 to 12 yr). Mean mandibular advancement at the B point was 24.3 mm and mean change in occlusal plane was -10.2°. Sixteen patients (76%) underwent maxillary orthognathic surgery for posterior downgrafting with rigid fixation and grafting. Long-term follow-up showed excellent stability of surgical movements with a decrease in TMJ and myofascial pain, headaches, and dietary restrictions. CONCLUSIONS: Patients with ICR can be effectively treated using total TMJ prostheses with maxillary orthognathic surgery when indicated for the correction of an associated dentofacial deformity. Use of alloplastic joint prostheses allows for the execution of large mandibular advancements in a predictable and accurate manner with a meaningful decrease in symptoms of TMJ dysfunction.

Temporomandibular joint arthrocentesis: outcomes under intravenous sedation versus general anesthesia.

PURPOSE: Although arthrocentesis of the temporomandibular joint (TMJ) has been shown to be an effective, minimally invasive surgical procedure, there is a paucity of literature that has examined its effectiveness under intravenous (IV) sedation compared with general anesthesia (GA) with a secure airway. PATIENTS AND METHODS: A retrospective analysis of patients with TMJ arthrocentesis was performed. Patients were divided into 2 groups based on type of anesthesia (sedation vs general) and location of surgery (office vs hospital). Visual analog scales were used to assess TMJ pain, headaches, jaw function, diet, and disability. Objective examinations were performed for maximum interincisal opening, lateral excursions, and TMJ sounds. RESULTS: Statistical improvements were seen for TMJ pain, headaches, dietary restrictions, jaw function, and disability. Patients reported an 80% satisfaction rate for surgery under IV sedation compared with a 95% satisfaction rate of patients who had surgery under GA. CONCLUSIONS: Arthrocentesis is effective for treatment of TMJ pain and acute closed-lock conditions irrespective of Wilkes classification (grades I to III). Ninety-five percent of patients reported immediate resolution or decrease of pain within the first postoperative week. Although the procedure is effective when performed under IV sedation in an office setup, superior clinical outcomes were noticed when the procedure was performed with a secure airway under GA.

Maxillofacial Gunshot Injuries at an Urban Level I Trauma Center­10-Year Analysis.

PURPOSE: To analyze the current trends in the presentation and surgical treatment of patients admitted with facial gunshot wounds (GSWs) at an urban level 1 trauma center. MATERIALS AND METHODS: Retrospective analysis of facial GSWs treated by the Department of Oral and Maxillofacial Surgery at Boston Medical Center from 2001 to 2011. The data were obtained from the institutional trauma registry and hospital records and analyzed with respect to the length of hospitalization, patient demographic data, treatment cost, and payments. RESULTS: During the study period, a total of 1,957 patients were admitted to the hospital with GSWs. Of these patients, 136 (6.9%) had injuries involving the facial region, 87% were men, and the most common injury was to neck zone III. Mandible fractures were encountered in 47% of the patients. The fractures were treated within 72 hours from admission for most patients; 22% of the patients required secondary surgical procedures, 20% of the patients had associated neurologic injuries, and 9% had cervical spine fractures. Angiography was performed in 60% of the patients, with 13% requiring embolization. Finally, 70% of the patients required airway management, and the overall patient mortality was 9%. CONCLUSION: Airway compromise was the most common life-threatening early problem. Patients admitted with higher stages of shock and lower mental status because of brain, vascular, and/or spinal cord injuries experienced prolonged hospitalization, increased treatment costs, and extended rehabilitation. Most of the facial GSWs presented as non-life-threatening injuries, but typically resulted in significant morbidity. The vast majority of injured patients relied on public aid or had no insurance.

Effects of cuts in Medicaid on dental-related visits and costs at a safety-net hospital.

We used data from Boston Medical Center, Massachusetts, to determine whether dental-related emergency department (ED) visits and costs increased when Medicaid coverage for adult dental care was reduced in July 2010. In this retrospective study of existing data, we examined the safety-net hospital's dental-related ED visits and costs for 3 years before and 2 years after Massachusetts Health Care Reform. Dental-related ED visits increased 2% the first and 14% the second year after Medicaid cuts. Percentage increases were highest among older adults, minorities, and persons receiving charity care, Medicaid, and Medicare.

Same day access: a viable alternative for outpatient clinical care.

OBJECTIVE: To present our experience with a novel, same-day access (SDA) scheduling model for outpatient clinical care in oral and maxillofacial surgery (OMS). STUDY DESIGN: The primary outcome variable was OMS patient scheduling in a hospital-based outpatient clinic. Patients were given a specific appointment time to be seen the same day they contacted the clinic. This SDA clinic was compared to previous patient scheduling models for patient satisfaction, appointment wait times, annual clinic volume, no-show rates, and access to care. RESULTS: Patient satisfaction increased to 80% with SDA scheduling compared with 20% to 40% with prior models. The average wait time for patients improved to 19 minutes compared with 330 minutes with the walk-in model. Forty patients were scheduled on the same day, and 96% of all patients who called the clinic were seen within 14 days with the SDA approach. Same-day access was the only model that met its volume and budgetary goals. CONCLUSIONS: The incorporation of SDA scheduling improves patient satisfaction and is a viable alternative to more traditional scheduling protocols for clinics suffering from volume, revenue, and access to care issues.

Readmission after orthognathic surgery.

OBJECTIVE: To evaluate the readmission rate after orthognathic surgery and identify associated risk factors. STUDY DESIGN: Retrospective analysis of patients who underwent orthognathic surgery and had an unexpected hospital admission, with or without return to the operating room (OR), within the first postoperative year. Study variables included sex, age, American Society of Anesthesiologists (ASA) status, type of surgery, concomitant third molar extraction, concomitant genioplasty, duration of surgery, first assistant experience, and duration of hospitalization. Bivariate associations were calculated between variables and readmission status. Chi-square and Fisher's Exact tests were used to compare categorical variables, and a 2-sample t test was used to compare continuous variables. RESULTS: There were 701 patients included in the study. The readmission rate was 9.70%. Twelve patients were managed non-surgically, and 56 patients required an OR procedure. The most common reason for readmission without return to the OR was an infection, and for reoperation was hardware removal. Age, sex, type of surgery, third molar extraction, genioplasty, duration of surgery, and experience of first assistant were not found to be predictors for readmission. CONCLUSIONS: Only ASA classification and duration of initial hospitalization were significant risk factors for readmission of patients within the first postoperative year after orthognathic surgery.

Lifestyle and career satisfaction among US-based oral and maxillofacial surgeons: Results of a nationwide survey.

OBJECTIVE: This study aims to investigate overall career satisfaction rate amongst US-based oral and maxillofacial surgeons (OMSs) and to evaluate possible predictors of professional stress and quality of life. STUDY DESIGN: Members of the American Association of Oral and Maxillofacial Surgeons were invited to complete an online survey-based assessment. Descriptive statistics were computed; univariate analysis was performed to identify predictors for satisfaction. RESULTS: The overall response rate was 29%. Most of respondents were male (88.6%), aged >45 years (71.7%), married (91.7%), and working at private and/or group-based practices (55.9%) for >15 years (66.6%). Most surgeons 91.3% reported being satisfied with their career with 84.9% willing to choose a career in OMS again. No significant difference was noted in satisfaction rates between academic and non-academic surgeons. On univariate analysis, no demographic characteristic was predictive of satisfaction. CONCLUSIONS: Reportedly, 91.3% of US-based OMSs have a significant degree of career satisfaction, and a majority would choose the specialty as their profession again.

Reconstruction of the TMJ and condyle in inflammatory arthritis.

Inflammatory arthritis presents a unique destructive process to the temporomandibular joint. This article provides information on the proper diagnosis, treatment planning, and surgical management aimed to provide patients with improvement in pain, function, stability and facial aesthetics. Additionally, it aims to provide a detailed insight on the joint reconstruction options including alloplastic joint replacement, autogenous joint replacement, orthognathic surgery and distraction osteogenesis.

Tunnel Regenerative Corticotomy (TURC): A modified approach in surgically-assisted orthodontics.

We present a modified surgical technique which encompasses a combination of surgically-assisted accelerated orthodontics and guided bone regeneration for combined surgical and orthodontic management of dental crowding and maxillary transverse deficiency malocclusions with minimally invasive surgery, in a rapid manner, and without the use of general anesthesia.

Buccal plate augmentation: a new alternative to socket preservation.

Alveolar ridge resorption occurs after tooth extraction and has the potential to either complicate implant placement or impair the final esthetic result. Techniques to preserve natural bone and soft tissue contours are of great interest to clinicians and patients because even subtle postextraction buccal plate resorption may have significant clinical effects, particularly in the esthetic zone. Buccal plate augmentation (BPA) is a novel approach for ridge preservation aiming to avoid recession of the facial wall of the socket without interfering with the natural healing mechanism of the extraction socket. It consists of placement of bone graft material over an intact buccal plate, underneath the soft tissues in a surgically created pouch with an aim to maintain or augment the soft tissue esthetics of the region.