Resorbable Versus Titanium Rigid Fixation for Pediatric Mandibular Fractures: A Systematic Review, Institutional Experience and Comparative Analysis

In Vivo Inflammatory Soft and Hard Tissue Response to Newly Developed Osteosynthesis Material for Pediatric Maxillofacial Traumatology in a Critical Size Bone Defect Model

Childhood trauma defects in the head and neck area are challenging in many aspects for patients and surgeons. One major issue is the still incomplete growth. Bone defect fixation measures have to consider biomechanical forces due to the bone growth from both sides, the bone growth possibly influencing and working against the fixation itself and vice versa. A solution will be the development of a stable but, at the same time, quickly degradable osteosynthesis system (OSS) specifically for the pediatric sector. Besides the physical demands, biocompatibility and low risk for unphysiological tissue response are exceptionally important. A newly developed PDLLA-derivate/chitosan hybrid material (PDLLA:CC:Mg+Chitosan) with promising features confirmed in vitro experimental set-ups has been tested in a critical size bone defect model in Wistar rats to confirm slow degradation and absence of unphysiological integration of the material, and of bone growth induced by the material itself. mCT and histologic analysis of implanted rat skulls after 1, 3, and 5 months confirmed slow degradation of the PDLLA:CC:Mg+Chitosan material without any unintended bone growth induction or morphologic changes due to the material. The results of this in vivo study confirmed the suitability of the material to serve as OSS in clinical practice.

Long-term Sequelae of Pediatric Maxillofacial Fractures

This study aimed to investigate the long-term sequelae of pediatric maxillofacial fractures and further analyze the causes of these sequelae. A case series study was conducted on children with long-term sequelae after maxillofacial fractures treated between January 2015 and December 2020 in our institution. Relevant preoperative, postoperative, and follow-up data were collected and analyzed. A total of 25 patients were included. The long-term sequelae of pediatric maxillofacial fractures included temporomandibular joint osteoarthritis (12/25), facial deformity (5/25), blindness (5/25), temporomandibular joint ankylosis (3/25), visual impairment (2/25), and permanent facial nerve injury (1/25). All cases of temporomandibular joint ankylosis involved concurrent fractures of the mandibular body and condyle, and all patients received conservative treatment. Preoperative CT scans showed lateral dislocation of the ramus stump and reduced joint space in all patients. All patients with facial deformities exhibited severely displaced fractures and had undergone inadequate fracture reductions. As a conclusion, surgical intervention should be considered for pediatric maxillofacial fractures when CT scans reveal lateral dislocation of the ramus stump and diminished joint space. For severely displaced pediatric maxillofacial fractures, anatomic reduction should be achieved during surgery to prevent facial deformities.

Pediatric Craniofacial Ballistic Injuries

Pediatric ballistic injuries are a public health crisis in the United States. Younger children are more likely to sustain craniofacial injuries, which are associated with higher mortality rates. An understanding of the timeline of craniofacial development and the variation in pediatric facial proportions over time is important to guide further treatment of these patients. Management of these patients includes initial stabilization according to the Advanced Trauma Life Support protocol followed by management of time-sensitive injuries. Ballistic injuries often result in soft tissue and bone defects, requiring fixation and coverage. As children experience faster rates of bone healing, fixation should be done promptly. Soft tissue coverage is dependent on the size of the defect; whereas smaller wounds can be closed with primary closure or local tissue rearrangement, larger wounds may require free tissue transfer.

Performance evaluation of a low-cost Ti-Mo-Fe (TMF8) as a replacement for Ti-6Al-4V for internal fixation implants used in mandibular angular fractures: a finite element analysis study

Stainless steel and titanium-based alloys have been the gold standard when it comes to permanent implants and magnesium-based alloys have been the best option for bioresorbable alloys. Ti-6Al-4V, Ti-64, with its 110 GPa Young's Modulus is the most commonly employed alloy to manufacture biomedical implants used for treatment of fractures of skeleton. Recently, researchers have developed a new low-cost and toxic Vanadium-free alternative to this alloy, Ti-3Mo-0.5Fe at.%, namely TMF8. This alloy has a 25% lesser Young's Modulus compared to Ti-6Al-4V and also demonstrated acceptable mechanical properties while possessing better cell proliferation results. The lower Young's Modulus can aid in lowering stress shielding effects while its cytocompatibility could enhance healing. This work, therefore, tries to use finite element analyses to compare these two alloys (Ti-64 and TMF8) from a practical structural point of view to analyse the advantages and disadvantages of this new alloy and how a low-cost biocompatible alternative (TMF8) can actually prove to be a more viable option. The analyses confirm that TMF8 shows almost similar biomechanics performance to Ti-64 alloy (and in acceptable range) in bone plate fixation of mandibular angular fracture treatment.

Management of Pediatric Mandibular Condyle Fractures: A Literature Review

This narrative review evaluates the literature on the management of mandibular condyle fractures in growing patients. It aims to illustrate some fundamental biological principles and to offer a series of considerations applicable to clinical practice. The discussion is based on 116 papers published in PubMed and two relevant textbooks. Condylar fractures may be overlooked, especially in pre-scholar children, where compliance is usually reduced. However, these injuries can have disabling sequelae such as ankyloses, facial deformities, malocclusion, and chronic pain in some patients if not diagnosed and managed correctly. Due to their significance, mandibular condyle fractures in children are a subject of considerable clinical interest. As of today, there is consensus about their treatment. Four management options are available: expectative (analgesia, soft food and follow-up), functional protocols (guiding elastics, orthodontic appliances and exercises), maxillomandibular fixation (MMF), and open reduction and internal fixation (ORIF). Nondisplaced and minimally displaced fractures should be treated expectantly; severely displaced non-comminuted fractures can be safely operated on if the expertise is available, even in patients with deciduous dentition. Moderately displaced fractures can be managed with functional protocols or operatively, depending on the background and know-how of the specialist. Functional protocols can achieve good outcomes, especially in patients with deciduous dentition. MMF should be foregone in children due to its many drawbacks.

Policy of fourteen maxillofacial divisions towards titanium plates removal after internal fixation of paediatric maxillofacial fractures: A World Oral Maxillofacial Trauma (WORMAT) project

INTRODUCTION

The aim of this 11-year retrospective multicentric study is to evaluate the policy of 14 maxillofacial surgery divisions in terms of titanium plate removal from paediatric patients who had undergone open reduction and internal fixation (ORIF) to treat maxillofacial fractures.

MATERIAL AND METHODS

Patients ≤ 16 years undergoing surgical treatment for fractures of middle and lower third of the face between January 2011 and December 2022, with a minimum follow-up of 6 months, were included. Age (group A: ≤ 6 years, B: 7-12 years, C: 13-16 years), sex, fracture location and type, surgical approach, number, and location of positioned and removed plates, timing and indications for removal were recorded.

RESULTS

191/383 (50 %) patients (median age, 10 years; M:F ratio 2.1:1) underwent removal of 319/708 (45 %) plates. Maxillary dentoalveolar process (91 %), angle/ramus (63 %) and mandibular body (61 %) had a significantly higher removal rate than other fracture sites (p < 0.001). A significant decreasing trend in removal with increasing age was observed, from 83 % in Group A to 24 % in Group C (p < 0.001). On the total of positioned plates, 11 % were removed for symptomatic reasons (5 % infections, 6 % discomfort/pain) and 34 % for other reasons (28 % scheduled removal).

DISCUSSION

This multicentric study showed that plate removal was not performed routinely in the paediatric population. The incidence and causes of symptomatic plates removal were consistent with the literature, while the plate removal rate from asymptomatic patients was lower. A correlation was found between increasing age and a reduction in the frequency of plate removal procedures.

Management of Mandibular Condyle Fractures in Pediatric Patients: A Multicentric Retrospective Study with 180 Children and Adolescents

Background: Mandibular condyle fractures in pediatric patients can lead to crippling sequelae such as ankylosis, pain and facial deformity if not managed properly. However, there is no consensus on the best approach for treating these fractures in children. Objective: This study aimed to describe the management of mandibular condyle fractures in growing patients across 14 maxillofacial departments worldwide. Methods: A retrospective multicenter study was conducted on children and adolescents aged 0 to 16 who had at least one mandibular condyle fracture. This study included patients who underwent expectant, closed, or open management and were treated over an 11-year period. Results: 180 patients had at least one mandibular condyle fracture, and 37 had a second condylar fracture. One hundred sixteen patients (65%) were males, and 64 (35%) were females (ratio 1.8:1). An expectant strategy was chosen in 51 (28%) patients, a closed treatment-stand-alone maxillomandibular fixation (MMF)-in 47 (26%), and open reduction and internal fixation (ORIF) was performed in 82 (46%) patients. The management varied significantly between the different departments (p < 0.0001). Significant differences were also identified between the fracture type (non-displaced, displaced or comminuted) and the management of the 180 patients with a single condylar fracture. Out of 50 non-displaced fractures, only 3 (6%) had ORIF, 25 (50%) had expectant management, and 22 (44%) had MMF. Out of 129 displaced fractures, 79 (62%) had ORIF, 25 (19%) had a soft diet, and 25 (19%) had MMF. Conclusions: Expectative management, MMF, and ORIF were all effective in treating pediatric mandibular condyle fractures, with a low incidence of complications and asymmetry.

Pediatric Head and Neck Trauma

The pediatric patient population has unique anatomic characteristics that bring challenges and increased risk to management. The purpose of this article is to guide the head and neck trauma surgeon in decision making for the treatment of pediatric head and neck trauma with an emphasis on facial fracture management.

Complications of Mandibular Fracture Repair

Mandible fracture management has evolved dramatically. Therefore, the variety of surgical complications associated with mandibular fractures, and their incidences, have continued to change as well. This article aims to assess the most common and most concerning complications that can occur secondary to management of mandibular fractures by examining categories of complication types. This article also explores factors and techniques associated with reduced rates of complications as well as the management of complications.

Rigid Fixation of the Pediatric Facial Skeleton

Pediatric facial fractures are uncommon, and fortunately, the majority can be managed with conservative measures. Rigid fixation of the pediatric facial skeleton can potentially be associated with delayed hardware issues and growth inhibition. When appropriate, resorbable fixation is most commonly used for this purpose. Titanium plates and screws are advantageous when rigid fixation is a priority because properly placed hardware that respects natural suture lines is not thought to significantly inhibit growth. Furthermore, titanium fixation may be removed following healing.

Pediatric Mandible Fractures

The management of pediatric facial fractures requires several considerations by the treating surgeon. Pediatric facial fractures occur less commonly than in adults. Among fracture patterns in children, studies have repeatedly demonstrated that mandible fractures are the most common facial fracture particularly the condyle. Most fractures in children are amenable to nonsurgical or closed treatment; however, certain indications exist for open treatment. The literature describing epidemiology, treatment trends, and long-term outcomes are limited in comparison with adult populations. The purpose of the article is to review the etiology, workup, and management of mandible fractures in children.

High Adherence of Oral Streptococcus to Polylactic Acid Might Explain Implant Infections Associated with PLA Mesh Implantation

The aim of this study was to evaluate and compare the biofilm formation properties of common pathogens associated with implant-related infections on two different implant material types. Bacterial strains tested in this study were Staphylococcus aureus, Streptococcus mutans, Enterococcus faecalis, and Escherichia coli. Implant materials tested and compared were PLA Resorb × polymer of Poly DL-lactide (PDLLA) comprising 50% poly-L-lactic acid and 50% poly-D-lactic acid) and Ti grade 2 (tooled with a Planmeca CAD-CAM milling device). Biofilm assays were done with and without saliva treatment to evaluate the effect of saliva on bacterial adhesion and to mimic the intraoral and extraoral surgical routes of implant placement, respectively. Five specimens of each implant type were tested for each bacterial strain. Autoclaved material specimens were first treated with 1:1 saliva-PBS solution for 30 min, followed by washing of specimens and the addition of bacterial suspension. Specimens with bacterial suspension were incubated for 24 h at 37 °C for biofilm formation. After 24 h, non-adhered bacteria were removed, and specimens were washed, followed by removal and calculation of adhered bacterial biofilm. S. aureus and E. faecalis showed more attachment to Ti grade 2, whereas S. mutans showed higher adherence to PLA in a statistically significant manner. The salivary coating of specimens enhanced the bacterial attachment by all the bacterial strains tested. In conclusion, both implant materials showed significant levels of bacterial adhesion, but saliva treatment played a vital role in bacterial attachment, therefore, saliva contamination of the implant materials should be minimized and considered when placing implant materials inside the body.

Rigid versus resorbable plate fixation in fronto-orbital advancement in unicoronal stenosis - A retrospective study

Introduction:

Rigid plating fixation (RPF) and resorbable plating systems (RPS) advanced the field of reconstruction in craniomaxillofacial region. However, their performance in patients, particularly the effect on bone remodeling at site of hardware placement is not much documented. This manuscript aims to compare the performance of RPF and RPS in a cohort using a retrospective audit of case records.

Methods:

Archival records were searched for patients who had undergone cranial metal-RPF or RPS or combination for the correction of craniofacial deformities following inclusion-exclusion criteria. From records, data of the quality and quantity of bone formed along the site of plate fixation as compared with the adjacent site, accommodating or facilitating brain growth, and persistence of bone deformity at the site of hardware placement were collected at the end of the follow-up period. A total of 128 sites from 18 individuals (6 with exclusive metal-RPF and 12 with RPS) mean age of 7.45 ± 7.28 (Median 4; IQR of 8.88;2.6–11.5) who underwent cranial bone remodeling surgery formed the study group.

Results:

There was a statistically significant difference between the RPF and PRS system at the fronto-orbital suture (P = 0.002) and coronal suture (P = 0.036) with bone quality and quantity.

Discussion:

The RPF system was rigid but had a set of issues, while RPS has advantages and limitations. The qualitative difference in between the two systems is different. Due to inherent dissimilarity, the two systems cannot be interchanged and due diligence has to be exercised while deciding on the system. More prospective studies are needed to validate the findings.