Mandibular Fractures: Diagnosis and Management

Evaluating the influence of sports-induced trauma on temporomandibular disorders: A systematic review and meta-analysis

OBJECTIVE

The main aim of this study was to identify the existing literature on the association between sporting activities and temporomandibular disorders and to critically appraise evidence of this association through a systematic review and meta-analysis.

DESIGN

A comprehensive search was conducted using PubMed, ScienceDirect, Dimensions, Google Scholar, Cochrane Library, and the Education Resources Information Centre (ERIC). Articles were selected using pre-specified eligibility criteria. In addition, the quality of eligible studies was assessed using the National Institutes of Health (NIH) for observational cohort and cross-sectional studies. Data were systematically extracted and analyzed.

RESULTS

Temporomandibular disorder symptoms, such as myofascial pain, clicking sounds, and musculoskeletal symptoms, were comparably prevalent among athletes and non-athletes, with some studies reporting contrasting results. However, meta-analyses of the comparisons demonstrated statistically insignificant differences between athletes and non-athletes. Additionally, there was a significant reduction in temporomandibular disorder symptoms when mouthguards were used.

CONCLUSIONS

This comprehensive analysis of existing evidence highlights the various symptoms and clinical manifestations of TMD among athletes, including myofascial pain, clicking sounds, and musculoskeletal symptoms. This study established different prevalence rates in different sports.

Efficacy of 3-Dimension Curved Angle Plate Versus 2 Miniplates in Mandibular Angle Fracture Fixation

In this study, the authors proposed to determine the superiority or inferiority of the 3D fixation method and 2 miniplate fixation methods in mandibular angle fractures. The purpose of this study was to evaluate the efficacy of a 3D curved angle strut plate and 2 miniplates in mandibular angle fracture fixation. The aim of this study was to evaluate the efficacy of 3-dimension curved angle strut plate versus 2 miniplates in mandibular angle fracture fixation. Sixteen patients requiring internal fixation of the mandibular angle fractures divided into 2 groups 8 in each group, group I was treated with using 3D curved angle strut plate. Group II was treated using two 2-mm miniplates. The results of this study suggested that there are statistically significant in time elapsed between plate adaptation and definitive fixation (min) between 2 groups. The 3D curved angle plate has relatively few or no postoperative complications compared with other techniques.

Evaluation of bone healing in trabeculae structure of mandibular corpus and angulus fracture patients with fractal dimension analysis

Background

Fractures of the mandibular corpus and angulus are affected by different forces result from different strength of the muscles that influenced them. Therefore, it is presumed that there is a different in healing rate. Fractal dimension radiologic analysis assesses the trabecular pattern, due to it can be used to observe the healing process of bone fractures.

Purpose

The study aimed to compare the healing process of mandibular corpus and angulus fractures with fractal dimension analysis (FD) of trabecular patterns on panoramic radiographs through ImageJ software as consideration to determine mastication loading time.

Methods

This retrospective cross-sectional study observed medical records and panoramic radiographs of patients with a diagnosis of corpus and or mandibular angulus fractures undergoing open reduction (ORIF) 1 plate treatment combined with maxillomandibular fixation (MMF) at Hospital in 2017-2023. Observations were carried out on postoperative 1st day, 2nd week, 8-13th week and >13th week respectively.

Results

Twenty-five subjects who met the inclusion requirements were involved in the study. The results of Two-Way ANOVA statistical test and Fisher's LSD post-hoc showed that the FD values of corpus fracture were significantly greater than that of mandibular angulus with p 0.000 (H1), 0.003 (H2), 0.03 (H3), 0.000 (H4) respectively. In both groups of mandibular corpus and angulus fractures, there was a significant effect of time with p = 0.00 in each group. The longer the observation time, the more trabeculae patterns were formed in the healing process of corpus and angulus fractures.

Conclusion

Post ORIF observation of corpus fracture shows a greater trabecula formation value which indicates faster healing when compared to mandibular angulus fracture.

Optimizing Osteotomy Geometries in Posterolateral Mandibulectomies

Importance

Reconstructive stability after mandibulectomy with osseous autogenous transplant is influenced by masticatory forces and the resulting stress on the titanium plate.

Objective

To determine an optimal geometry of mandibular osteotomy that minimizes undesirable loading of the reconstruction plate.

Design, Setting, and Participants

In this combined in silico and in vitro basic science study, segmented computed tomography images of an adult male human mandible downloaded from the Visible Human Project were analyzed. Data were collected from July to November 2023.

Exposures

Four posterolateral mandibular resections and bony transplants were modeled following (1) vertical, (2) angled, (3) step, and (4) sagittal osteotomies. Using SOLIDWORKS software, mastication was simulated under (1) incisal, (2) ipsilateral molar, and (3) contralateral molar loading. Mandible models were then 3-dimensionally printed, osteotomized, and plated. Masticatory loads were simulated using pulleys, and strains were measured using strain gauges.

Main Outcomes and Measures

On the reconstruction plate, von Mises stresses were measured in silico, and strains were measured using strain gauges in vitro. Stress and strain are reactions of a material to loading that can result in irreversible deformation or fracture.

Results

In silico, maximum plate stress was highest with the vertical osteotomy, followed by the angled osteotomy (median difference vs vertical: ipsilateral molar loading, 126 MPa; 95% CI, 18-172; incisal loading, -24 MPa; 95% CI, -89 to 31; contralateral molar loading, 91 MPa; 95% CI, 23-189), step osteotomy (median difference vs angled: ipsilateral molar loading, 168 MPa; 95% CI, 112-235; incisal loading, 80 MPa; 95% CI, 15-140; contralateral molar loading, -17; 95% CI, -115 to 83), and sagittal osteotomy (median difference vs step: ipsilateral molar loading, 122 MPa; 95% CI, 102-154; incisal loading, 197 MPa; 95% CI, 166-230; contralateral molar loading, 161 MPa; 95% CI, 21-232). An angled osteotomy had the lowest stress at 30° of angulation (median difference vs contralateral molar loading at 40° of angulation: 111 MPa; 95% CI, 4-186). In vitro, the vertical osteotomy had the highest maximum strain, followed by the angled osteotomy (mean difference vs vertical: incisal loading, 0.021 mV/V; 95% CI, 0.014-0.027; contralateral molar loading, 0 mV/V; 95% CI, -0.004 to 0.005), step osteotomy (mean difference vs angled: incisal loading, 0.015 mV/V; 95% CI, 0.003-0.028; contralateral molar loading, 0.021 mV/V; 95% CI, 0.016-0.027), and sagittal osteotomy (mean difference vs step: incisal loading, 0.006 mV/V; 95% CI, -0.006 to 0.018; contralateral molar loading, 0.020 mV/V; 95% CI, 0.015-0.026).

Conclusions and Relevance

In this study, the traditional vertical osteotomy resulted in less favorable plate stresses in all loading scenarios compared with angled, step, or sagittal osteotomies, in silico and in vitro. Future clinical studies analyzing the impact of varying osteotomy geometries are warranted to translate these findings to the operating room.

Conservative versus Surgical Approaches in the Treatment of Intracapsular Condylar Fractures: A Retrospective Study

The diagnosis and management of intracapsular condylar fractures (ICFs) are crucial, and if left untreated, they can cause facial asymmetry, limited mouth opening, and even temporomandibular joint (TMJ) ankylosis, which may affect the physical function and mental health of patients. Various procedures have been described for the ICFs, but there is no consensus on the therapeutic methods. This study aimed to compare the clinical efficacy of conservative and surgical management of ICFs.

Opioid Use Following Open Reduction and Internal Fixation of Mandibular Fractures

A mandible fracture is a common traumatic craniofacial injury for which surgery is sometimes indicated. Post-fracture and postoperative pain are often controlled through prescribed narcotics, which have received increased attention for potential abuse. The current work identified 90-day opioid prescribing patterns following surgically treated mandible fractures. Patients who underwent open reduction and internal fixation to treat a closed mandible fracture between 2011 and 2021 were identified in the PearlDiver Mariner165 database. Exclusion criteria included: (1) patients with records active for fewer than 180 days before the injury and 90 days post-fracture, (2) age younger than 18, and (3) those with long bone fracture within 30 days of mandible fracture. Variables associated with filling an opioid prescription and utilizing excess morphine milligram equivalents (MMEs) were identified through multivariate regression. Prescribing patterns between 2011 and 2021 were analyzed using simple linear regression. A total of 15,049 patients were identified. Of these patients, opioid prescriptions were filled by 10,389 (69.0%). Greater MMEs were filled for those with greater age, prior opioid use, and history of chronic pain ( P < 0.01 for all). The proportion of patients who received opioids decreased from 2011 to 2021 (73.3% versus 61.9%) during which declines were also seen for median MMEs (225.0 versus 128.4) and mean number of filled prescriptions (4.1 versus 2.8). The present work identified age and preexisting risk factors as significantly associated with excess MMEs following open reduction and internal fixation-treated mandible fracture. The decreasing proportion of patients receiving opioids along with decreasing MMEs suggests more refined practice with regard to their use.

Utility of Generative Artificial Intelligence for Patient Care Counseling for Mandibular Fractures

OBJECTIVE

To determine the readability and accuracy of information regarding mandible fractures generated by Chat Generative Pre-trained Transformer (ChatGPT) versions 3.5 and 4o.

BACKGROUND

Patients are increasingly turning to generative artificial intelligence to answer medical queries. To date, the accuracy and readability of responses regarding mandible fractures have not been assessed.

METHODS

Twenty patient questions regarding mandible fractures were developed by querying AlsoAsked (https://alsoasked.com), SearchResponse (https://searchresponse.io), and Answer the Public (https://answerthepublic.com/). Questions were posed to ChatGPT 3.5 and 4o. Readability was assessed by calculating the Flesch Kincaid Reading Ease, Flesch Kincaid Grade Level, number of sentences, and percentage of complex words. Accuracy was assessed by a board-certified facial plastic and reconstructive otolaryngologist using a 5-point Likert Scale.

RESULTS

No significant differences were observed between the two versions for readability or accuracy. Readability was above recommended levels for patient education materials. Accuracy was low, and a majority of responses were deemed inappropriate for patient use with multiple inaccuracies and/or missing information.

CONCLUSION

ChatGPT produced responses written at a high level inappropriate for the average patient, in addition to containing several inaccurate statements. Patients and clinicians should be aware of the limitations of generative artificial intelligence when seeking medical information regarding mandible fractures.

Novel Tripartite Classification for Fractures of Coronoid Process of Mandible: A Retrospective Tertiary Center Study

Introduction

Coronoid process of mandible is seldom fractured during maxillofacial trauma. Majority of the cases of coronoid fracture are treated conservatively, but some lead to complications which are often overlooked. At present, the literature on coronoid fractures is inadequate for meta-analysis. Also, there exists no standardized classification in the literature. Hence, the purpose of this study was to analyze the incidence and establish a novel 'tripartite' classification.

Material and Methods

In this study carried out at level 1 trauma center, all patients with coronoid fracture with or without associated maxillofacial fractures were included. Relevant data were noted from Hospital records and CT scans (computer tomographic scans). These cases were classified according to 'tripartite' classification and treated. Data feed was given to IBM® SPSS® statistics (version 21) for analysis.

Results

Among 33 coronoid fracture patients, majority (57.57% cases) were from age group of 21-40 years with 82.85% cases attributed to road traffic accidents. 11.43% cases were bilateral, and the rest unilateral cases revealed right-side predilection.

Conclusion

Novel tripartite classification allows us to easily categorize and visualize the coronoid fractures. Horizontal types 1 to 3 and vertical types 4 to 6 are in increasing order of incidence, which makes it easy for communication, treatment approach and record maintenance.

Mandibular biomechanics rehabilitated with different prosthetic restorations under normal and impact loading scenarios

BACKGROUND

Restorative treatment options for edentulous patients range from traditional dentures to fixed restorations. The proper selection of materials greatly influences the longevity and stability of fixed restorations. Most prosthetic parts are frequently fabricated from titanium. Ceramics (e.g. zirconia) and polymers (e.g. PEEK and BIOHPP) have recently been included in these fabrications. The mandibular movement produces complex patterns of stress and strain. Mandibular fractures may result from these stresses and strains exceeding the critical limits because of the impact force from falls or accidents. Therefore, it is necessary to evaluate the biomechanical behavior of the edentulous mandible with different restorations under different loading situations.

OBJECTIVE

This study analyzes the biomechanical behavior of mandibles after four prosthetic restorations for rehabilitation under normal and impact loading scenarios.

MATERIAL AND METHODS

The mandibular model was constructed with a fixed restoration, which was simulated using various materials (e.g. Titanium, Zirconia & BIOHPP), under frontal bite force, maximum intercuspation, and chin impact force. From the extraction of tensile and compressive stresses and strains, as well as the total deformation of mandible segments, the biomechanical behavior and clinical situations were studied.

RESULTS

Under frontal bite, the anterior body exhibited the highest tensile (60.34 MPa) and compressive (108.81 MPa) stresses using restoration 4, while the condyles and angles had the lowest tensile (7.12 MPa) and compressive (12.67 MPa) stresses using restoration 3. Under maximum intercuspation, the highest tensile (40.02 MPa) and compressive (98.87 MPa) stresses were generated on the anterior body of the cortical bone using restoration 4. Additionally, the lowest tensile (7.7 MPa) and compressive (10.08 MPa) stresses were generated on the condyles and angles, respectively, using restoration 3. Under chin impact, the highest tensile (374.57 MPa) and compressive (387.3 MPa) stresses were generated on the anterior body using restoration 4. Additionally, the lowest tensile (0.65 MPa) and compressive (0.57 MPa) stresses were generated on the coronoid processes using restoration 3. For all loading scenarios, the anterior body of the mandible had the highest stress and strain values compared with the other segments. Compared to the traditional titanium restoration.2, restoration.1(zirconia) increases the tensile and compressive stresses and strains on the mandibular segments, in contrast to restoration.3 (BIOHPP). In addition, zirconia implants exhibited higher displacements than the other implants.

CONCLUSION

In the normal loading scenario, the tensile and compressive stresses and strains on the mandible were within the allowable limits when all restorations were used. Under the chin impact loading scenario, the anterior body of the mandible was damaged by restorations 1 and 4.

Comparison of Patterns and Demographics of Isolated Traumatic Mandibular Fracture Between Incarcerated and General Populations

Introduction The management of maxillofacial trauma can be challenging in different unique clinical presentations. While maxillofacial fractures vary in location based on the mechanism of injury, the mandibular fracture is noted to be one of the most common facial fractures. The objective of this study was to explore the differences in injury patterns, outcomes, and demographics of isolated traumatic mandibular fractures between incarcerated and general populations. Methods This retrospective study analyzed consecutive patients presenting for trauma care from January 1, 2010, to December 31, 2020, at the Arrowhead Regional Medical Center (ARMC). Patients 18 years and older were included in this study. Patients diagnosed with mandibular fracture as the primary diagnosis at admission and discharge were identified using the International Classification of Disease, Ninth and Tenth Revision (ICD-9, ICD-10) Code. Patient demographics were extracted from their electronic medical records and included race, marital status, and insurance status. Results A total of 1080 patients with confirmed mandibular fractures were included in the final analysis. Among these patients, 87.5% (n=945) were males, 40% (n=432) of the patients were Hispanic, and the average age was 31.55 years old. The most common mechanism of injury was blunt trauma secondary to assault. Compared to the general population with mandibular fracture, the incarcerated patients with mandibular fracture were more likely to be males (96.1% vs 86.1% for incarcerated population vs. general population respectively, p=0.0005). No other variables were statistically different between these two groups. Conclusion The evidence from this study suggests that the patterns, outcomes, and demographics of mandibular fracture in both incarcerated and general populations are similar.

Off-Label Use of an External Hand Fixator for Craniomaxillofacial Fractures-An Anatomical Feasibility Study

BACKGROUND

The lack of resources limits the treatment of craniomaxillofacial fractures (CMF) in low-income countries (LIC). Therefore, Barton bandages and/or interdental wiring are considered in these regions. Fracture reduction is maintained by permanent occlusion for 6 weeks, which often leads to limited compliance and dissatisfying results. The aim of this cadaver-based study is to evaluate the feasibility of the use of an external face fixator (EFF) for the treatment of CMF, its biomechanical values and to define the optimal pin insertion points and angles.

MATERIALS AND METHODS

An AO hand fixator was used. CMF of types Le Fort 1-3 with split fractures of the hard palate were treated with EFF on 13 anatomical specimens. Fractures were created using a chisel, and pins were placed in specific anatomical regions. The maximal pull-out force [N] of pins was analysed by a tensile force gauge, and Fmax of the mandibular pins was evaluated. Computer tomography scans were performed on the healthy, fractured and EFF-treated skulls.

RESULTS

The pull-out forces for the single pins were mandibular pins (n = 15, median 488.0 N), supraorbital pins (n = 15, median 455.0 N), zygomatic pins (n = 14, median 269.1 N), medial hard palate pins (n = 12, median 208.4 N) and lateral hard palate pins (n = 8, median 49.6 N).

CONCLUSIONS

The results indicate that the operation technique is feasible, and the stability of the EFF is sufficient for maintaining the reduction. The required pins can safely be inserted into the described areas with good reduction results. Using EFF offers a feasible alternative to the non-surgical treatment of CMF in LIC.

The risk of osteomyelitis after mandibular fracture is doubled in men versus women: analysis of 300,000 patients

Postoperative complications following mandibular fracture treatment vary from local wound infections to severe conditions including osteomyelitis and impaired fracture healing. Several risk factors have been associated with the development healing disorders, including fracture localisation, treatment modality and substance abuse. However, limited research on the sex-specific influence of these complications exists. A total of about 300,000 female and male patients with mandibular fractures were examined in two cohorts. After matching for confounders (age, nicotine and alcohol dependence, malnutrition, overweight, anaemia, diabetes, osteoporosis and vitamin D deficiency), two cohorts were compared with propensity-score-matched patients according to outcomes (osteomyelitis, pseudoarthrosis and disruption of the wound) within 1 year after fracture. There were significant differences between female and male patients regarding the occurrence of osteomyelitis (odds ratio [OR] [95% confidence interval]: 0.621 [0.563; 0.686]) and disruption of the wound (OR [95% confidence interval]: 0.703 [0.632; 0.782]). Surprisingly, matching for the expected confounders did not change the results substantially. Sex plays a dominant role in determining the risk stratification for postoperative osteomyelitis and disruption of the wound, after accounting for other potential confounding factors. Additional research is needed to understand the underlying mechanisms and to develop sex-specific strategies to prevent these complications.

Intermaxillary Fixation in the Primary and Mixed Dentition

Anatomic differences of the primary dentition may hinder traditional methods of intermaxillary fixation. Furthermore, the presence of both the primary and permanent dentition can complicate establishing, and maintaining, the preinjury occlusion. The treating surgeon must be aware of these differences for optimal treatment outcomes. This article discusses and illustrates methods that facial trauma surgeons can use to establish intermaxillary fixation in children aged 12 years and younger.

Clinical Patterns and Treatment of Pediatric Facial Fractures: A 10-Year Retrospective Romanian Study

Pediatric facial fractures have different clinical patterns and require different therapeutic approaches in comparison with those of facial fractures that occur among adults. The aim of this study was to describe the main clinical characteristics of pediatric facial fractures (such as fracture location, fracture pattern, treatment, complications and evolution) in a group of pediatric patients from NW Romania. This research was a retrospective study that was conducted for 10 years in a tertiary hospital for oral and maxillofacial surgery from NW Romania. A total of 142 pediatric patients were included in this study, with ages between 0 and 18 years. Mandibular (66.2%), midface (25.4%) and combined fractures (8.5%) were identified, and patients from the 13-18 years age group were more frequently affected by facial fractures (78.9%). Most of the diagnosed fractures among all three types of fractures were total fractures, and most mandibular (92.6%) and midface (80.6%) fractures were without displacement. Hematomas, lacerations and abrasions were identified as associated lesions. Patients with associated lesions were more frequently associated with combined fractures or midface fractures than mandibular fractures. The instituted treatment was, in general, orthopedic, for all three types of fractures (mandibular-86.2%; midface-91.7%; combined-66.7%). Most fractures, mandibular (96.8%), midface (100%) and combined (91.7%) fractures, had a favorable evolution. Most fractures did not present any complications at the follow-up. Pediatric facial fractures have unique patterns and must be treated with caution, considering the particularities of pediatric facial anatomy.