Current Strategies for Treatment of Mandibular Fractures With Plate Osteosynthesis: A European Prospective Study

PURPOSE

The training and preferences of surgeons influence the type of surgical treatment for mandibular fractures. This multicentre prospective study analyzed the current treatment strategies and outcomes for mandibular fractures with open reduction and internal fixation (ORIF).

MATERIAL AND METHODS

This prospective study included patients aged ≥16 years who underwent ORIF for mandibular fractures in 12 European maxillofacial centers. Age, sex, pretrauma dental status, fracture cause, site and type, associated facial fractures, surgical approach, plate number and thickness (≤1.4 or ≥1.5 mm), duration of postoperative maxillomandibular fixation, occlusal and infective complications at 6 weeks and 3 months, and revision surgeries were recorded.

RESULTS

Between May 1, 2021 and April 30, 2022, 425 patients (194 single, 182 double, and 49 triple mandibular fractures) underwent ORIF for 1 or more fractures. Rigid osteosynthesis was performed for 74% of fractures and was significantly associated with displaced (P=0.01) and comminuted (P=0.03) fractures and with the number of nonsurgically treated fracture sites (P=0.002). The angle was the only site associated with nonrigid osteosynthesis (P<0.001). Malocclusions (5.6%) and infective complications (5.4%) were not associated with osteosynthesis type.

CONCLUSION

Rigid osteosynthesis was the most frequently performed treatment at all fracture sites, except the mandibular angle, and was significantly associated with displaced and comminuted fractures and the number of nonsurgically treated fracture sites. No significant differences were observed regarding postoperative malocclusion or infections among osteosynthesis types.

Does the type of craniomaxillofacial fracture (CMF) differ between patients with intracranial hemorrhage (ICH) and those with blunt cerebrovascular injury (BCVI)? A retrospective study

The purpose of the present study was to investigate and compare craniomaxillofacial fracture (CMF) type in patients with intracranial hemorrhage (ICH) versus blunt cerebrovascular injury (BCVI). A retrospective cohort study was performed. The predictor variables were the types of CMF. The primary outcomes variables were ICH and BCVI. Secondary outcomes were death and survival with or without neurological sequelae. Descriptive, bivariate, and multiple logistic regression statistics were computed, and the significance level was set at P ≤ 0.05. The sample was composed of 1440 patients with a mean age of 46.6 years ±24 years, and 71% were men. Pure orbital wall (odds ratio [OR]), 3.62; 95% confidence interval [CI], 1.32-12.69; P < 0.022), Le Fort III (OR, 16.08; 95% CI, 5.89-43.50; P < 0.001), cranial vault (OR, 9.74; 95% CI, 3.83.24.32; P < 0.001), skull base (OR, 9.42; 95% CI, 3.86-24.02; P < 0.001) and cervical fractures (OR, 5.50; 95% CI, 1.65-15.97; P = 0.003) were significantly associated with BCVI. All of the CMFs (P < 0.001), except for Le Fort I (OR, 0.79; 95% CI, 0.18-2.63; P = 0.731), nasal (OR, 1.05; 95% CI, 0.77-1.42; P = 0.758), and mandibular (OR, 0.68; 95% CI, 0.45-1.01; P = 0.066) fractures, were significantly associated with ICH. Secondary outcomes were negatively influenced by ICH and BCVI (P < 0.001). Within the limitations of the study it seems that Le Fort I and nasal fractures could be protective of cerebrovascular injuries, by cushioning impact forces. On the other hand it seems that patients with pure orbital wall, Le Fort III and cranio-cervical fractures are more prone to having concomitant life-threatening cerebrovascular injuries. This category of patients should have an immediate and comprehensive neurological assessment and CT angiography to rule out BCVI and to determine its severity.

Manual versus rigid intraoperative maxillo-mandibular fixation in the surgical management of mandibular fractures: A European prospective analysis

PURPOSE

Intraoperative stabilisation of bony fragments with maxillo-mandibular fixation (MMF) is an essential step in the surgical treatment of mandibular fractures that are treated with open reduction and internal fixation (ORIF). The MMF can be performed with or without wire-based methods, rigid or manual MMF, respectively. The aim of this study was to compare the use of manual versus rigid MMF, in terms of occlusal outcomes and infective complications.

MATERIALS AND METHODS

This multi-centric prospective study involved 12 European maxillofacial centres and included adult patients (age ≥16 years) with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate or partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, modality of intraoperative MMF (manual or rigid), outcome (minor/major malocclusions and infective complications) and revision surgeries. The main outcome was malocclusion at 6 weeks after surgery.

RESULTS

Between May 1, 2021 and April 30, 2022, 319 patients-257 males and 62 females (median age, 28 years)-with mandibular fractures (185 single, 116 double and 18 triple fractures) were hospitalised and treated with ORIF. Intraoperative MMF was performed manually on 112 (35%) patients and with rigid MMF on 207 (65%) patients. The study variables did not differ significantly between the two groups, except for age. Minor occlusion disturbances were observed in 4 (3.6%) patients in the manual MMF group and in 10 (4.8%) patients in the rigid MMF group (p > .05). In the rigid MMF group, only one case of major malocclusion required a revision surgery. Infective complications involved 3.6% and 5.8% of patients in the manual and rigid MMF group, respectively (p > .05).

CONCLUSION

Intraoperative MMF was performed manually in nearly one third of the patients, with wide variability among the centres and no difference observed in terms of number, site and displacement of fractures. No significant difference was found in terms of postoperative malocclusion among patients treated with manual or rigid MMF. This suggests that both techniques were equally effective in providing intraoperative MMF.

Emerging Strategies for the Biofabrication of Multilayer Composite Amniotic Membranes for Biomedical Applications

The amniotic membrane (AM) is the innermost part of the fetal placenta, which surrounds and protects the fetus. Due to its structural components (stem cells, growth factors, and proteins), AMs display unique biological properties and are a widely available and cost-effective tissue. As a result, AMs have been used for a century as a natural biocompatible dressing for healing corneal and skin wounds. To further increase its properties and expand its applications, advanced hybrid materials based on AMs have recently been developed. One existing approach is to combine the AM with a secondary material to create composite membranes. This review highlights the increasing development of new multilayer composite-based AMs in recent years and focuses on the benefits of additive manufacturing technologies and electrospinning, the most commonly used strategy, in expanding their use for tissue engineering and clinical applications. The use of AMs and multilayer composite-based AMs in the context of nerve regeneration is particularly emphasized and other tissue engineering applications are also discussed. This review highlights that these electrospun multilayered composite membranes were mainly created using decellularized or de-epithelialized AMs, with both synthetic and natural polymers used as secondary materials. Finally, some suggestions are provided to further enhance the biological and mechanical properties of these composite membranes.

Contribution of 3D printing for the surgical management of jaws cysts and benign tumors: A systematic review of the literature

BACKGROUND

Three-dimensional (3D) printing is now a widely recognized surgical tool in oral and maxillofacial surgery. However, little is known about its benefits for the surgical management of benign maxillary and mandibular tumors and cysts.

PURPOSE

The objective of this systematic review was to assess the contribution of 3D printing in the management of benign jaw lesions.

METHODS

A systematic review, registered in PROSPERO, was conducted using PubMed and Scopus databases, up to December 2022, by following PRISMA guidelines. Studies reporting 3D printing applications for the surgical management of benign jaw lesions were considered.

RESULTS

This review included thirteen studies involving 74 patients. The principal use of 3D printing was to produce anatomical models, intraoperative surgical guides, or both, allowing for the successful removal of maxillary and mandibular lesions. The greatest reported benefits of printed models were the visualization of the lesion and its anatomical relationships to anticipate intraoperative risks. Surgical guides were designed as drilling locating guides or osteotomy cutting guides and contributed to decreasing operating time and improving the accuracy of the surgery.

CONCLUSION

Using 3D printing technologies to manage benign jaw lesions results in less invasive procedures by facilitating precise osteotomies, reducing operating times, and complications. More studies with higher levels of evidence are needed to confirm our results.

Identifying Risk Factors Associated with Major Complications and Refractory Course in Patients with Osteomyelitis of the Jaw: A Retrospective Study

Despite improved knowledge regarding the diagnosis and treatment of osteomyelitis of the jaw (OMJ), it remains a clinical challenge for oral and maxillofacial surgeons. This study aimed to identify risk factors associated with severe forms of OMJ, i.e., related to the occurrence of major complications or the refractory course of the disease. A retrospective study was performed based on the medical records of all patients diagnosed with OMJ from the past 20 years. Collected data included demographic information, medical and dental history, clinical, radiological, and bacterial findings as well as treatment modalities. The main outcome variables were the onset of major complications and treatment results. Fifty-four patients were included. Our results showed that alcohol and smoking habits, as well as malnutrition, were significantly associated with the occurrence of major complications. We also established that dental implant-induced OMJ should be considered an aggressive subtype of OMJ. Finally, clinical bone exposure was significantly associated with unfavorable outcomes, whereas dental causes or radiological evidence of periosteal reaction were predictive of successful outcomes. Identifying such factors could be useful in preventing serious complications and informing patients about the refractory course of the disease based on the presence of these factors.

The Use of Equimolar Mixtures of Nitrous Oxide and Oxygen in Oral Surgery-A Retrospective Study of Patients in a Swiss University Hospital Setting

PURPOSE

The purpose of the study was to evaluate the success of procedural conscious sedation using inhaled equimolar nitrous oxide-oxygen (NOIS-EMONO) in patients undergoing routine dental and oral surgery procedures in a Swiss university hospital setting.

MATERIALS AND METHODS

The authors conducted a retrospective cohort study of patients that underwent NOIS-supported procedures between 2018 and 2022 at the oral surgery department of the University Hospital of Geneva (HUG), Switzerland. The primary outcome was the measurement of the procedure's success and efficacy as defined by the European Society of Anesthesiology. Secondary objectives included the analysis of the types of treatments performed, their indications, patient behavior, and the patient-clinician satisfaction score.

RESULTS

55 patients were included in the study; 85% underwent surgical procedures, and the remaining 15% underwent restorative and preventive procedures. The overall treatment success rate was 98.2% and 97.9% for surgically treated patients. Out of the patients, 62% appeared relaxed, calm, and serene, while 16% expressed pain or fear during the procedure. Infiltrative administration of local anesthesia caused stress in 22% of patients. This portion was significantly lower in sub-cohorts who received local topical anesthetics (0%) or a combination of systemic and local topical analgesics (7%). Patients (75%) and clinicians (91%) were satisfied with the procedure.

CONCLUSION

Inhaled equimolar nitrous oxide-oxygen procedural sedation used during dental procedures and oral surgery results in high treatment success and satisfaction rates. The administration of additional topical anesthetics helps to reduce the anxiety and stress related to infiltrative anesthesia. Further dedicated studies and prospective trials are needed to confirm these findings.

European multicenter prospective analysis of the use of maxillomandibular fixation for mandibular fractures treated with open reduction and internal fixation

INTRODUCTION

The goal of mandibular fracture treatment is to restore static and dynamic occlusal functions. Open reduction and internal fixation (ORIF) of these fractures can be associated with an intraoperative and/or postoperative maxillo-mandibular fixation (MMF). The aim of this study was to analyse the use of perioperative MMF and its effects on occlusal outcomes in the management of mandibular fractures.

MATERIAL AND METHODS

This multicentric prospective study included adult patients with mandibular fractures treated with ORIF. The following data were collected: age, gender, pre-trauma dental status (dentate, partially dentate), cause of injury, fracture site, associated facial fractures, surgical approach, type of ORIF (rigid, non-rigid or mixed), thickness and number of plates, modality of intraoperative MMF (arch bars, self-tapping and self-drilling screws [STSDSs], manual, other) and duration of postoperative MMF. The primary outcome was malocclusion at 6 weeks and 3 months. Statistical analyses were performed with Fisher's exact test or chi-square test, as appropriate.

RESULTS

Between 1 May 2021 and 30 April 2022, 336 patients, 264 males and 72 females (median age, 28 years) with mandibular fractures (194 single, 124 double and 18 triple fractures) were hospitalized. Intraoperative MMF was performed in all patients. Osteosynthesis was rigid in 75% of single fractures, and rigid or mixed in 85% and 100% of double and triple fractures, respectively. Excluding patients who underwent manual reduction, postoperative MMF (median duration, 3 weeks) was performed in 140 (64%) patients, without differences by type or number of fractures (p > 0.05). No significant difference was found in the incidence of malocclusion in patients with postoperative MMF (5%, 95% confidence interval [CI], 2-10%) compared to those without (4%; 95% IC, 1-11%) (p > 0.05).

CONCLUSION

Postoperative MMF was performed in more than half of the patients despite adequate fracture osteosynthesis, with wide variability amongst centers. No evidence of a reduction in the incidence of postoperative malocclusion in patients treated with postoperative MMF was found.

Computer-Aided Design and Computer-Aided Modeling (CAD/CAM) for Guiding Dental Implant Surgery: Personal Reflection Based on 10 Years of Real-Life Experience

Traditional dental implant surgery has been challenged by the phenomenal progression in computer-assisted surgery (CAS) that we have been witnessing in recent years. Among the computer-aided technologies, computer-aided design and computer-aided manufacturing (CAD/CAM) techniques represent by far the most attractive and accepted alternatives over their dynamic counterpart, navigational assistance. Based on many years of experience, we have determined that CAD/CAM technology for guiding dental implant surgery is valuable for rehabilitation of the anterior maxillary region and the management of complete or severe partial edentulism. The technology also guarantees the 3D parallelism of implants. The purpose of the present report is to describe indications for use of CAD/CAM dental implant guided surgery. We analyzed the clinical and radiological data of thirteen consecutive edentulous patients treated using CAD/CAM techniques. All of the patients had stable cosmetic results with a high rate of patient satisfaction at the final follow-up examination. No intra- and/or postoperative complications were encountered during any of the steps of the procedure. The application of CAD/CAM techniques produced successful outcomes in the patients presented in this series.

The lockdown effect: The impact of the COVID-19-related confinement on the nature of dental emergencies and the number of patients seen at the Geneva university hospital's dental clinic

Purpose

The aim of this retrospective case study was to evaluate the impact of the COVID-19 confinement on consultation number and nature of dental emergencies.

Materials and Methods

The investigators implemented a retrospective case-control study and enrolled a sample of patients who presented to the University Hospital of Geneva for dental emergencies during the COVID-19 confinement from March 16 to April 26, 2020. They were compared to a matched case-control group treated in 2018 and 2019. The predictor variable was the COVID-19 confinement. The outcome variables were consultation number and nature of dental emergencies. Other study variables included age, gender, socio-economic status, delay from symptoms to consultation and type of treatment. Descriptive and bivariate statistics were computed and significance level was set at ≤ 0.05.

Results

The study sample was composed of 1104 patients, with 386 in the case-study and 718 in the control group. No significant change in patient numbers was observed. In the case-study group patients were significantly younger (P= 0.004), had a significantly higher proportion of acute toothache and dental infections (P= 0.01), the main reason for consultation was pain or swelling (P= 0.01) and the delay from first symptoms to consultation was shorter compared to the controls (P=0.008).

Conclusion

The COVID-19 confinement had no impact on the consultation number of dental emergencies. However, changes in emergency type were noted, with an increase in acute toothaches and infections and patients waited less time between the onset of symptoms to consultation.

Reflections on a patient-centered approach to treatment of blow-out fractures: Why the wisdom of the pastmust guide our decision-making

The management of blow-out orbital fractures (BOFs) continues to be controversial and regularly questioned. In recent years, treatment decision-making has shifted from a clinically dominated emphasis to a more objective data-based approach. This has come about through the refinement of imaging technologies that can more precisely define the fracture itself. Decision-making is now mainly driven by computed tomography (CT) parameters among which the fracture's size is by far the most often used. The variability in a patient's clinical presentation and outcomes for similar types of BOFs raises serious doubts about the pertinence of applying standardized guidelines based on quantitative data for the treatment of individual patients. An approach that fails to include patient variability and relies too heavily on average objective results with an emphasis on the application of quantitative rather than qualitative methods can lead to poor patient outcomes. A review of the knowledge accumulated over the many years of treatment of BOFs has demonstrated that despite the exceptional imaging-based technologies available, clinical acumen remains the most sophisticated decision-assistive tool. Thus, the treatment of BOFs must be regarded as a patient rather than merely a geometrical imaging issue. Imaging then becomes a valuable diagnostic rather than a final decision-making tool. This more conservative approach leads to a substantial decrease in indications for surgical repair.

Dental implants in patients suffering from autoimmune diseases: A systematic critical review

PURPOSE

This systematic review aimed to evaluate complications and survival rates of dental implants placed in patients suffering from autoimmune diseases.

MATERIALS AND METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines (PRISMA), using Google scholar and PubMed electronic databases with a stop date of September 2021. The eligibility criteria included all full text human studies in the English language literature reporting on patients with autoimmune diseases treated with dental implants.

RESULTS

Fifty-five studies reporting on nine distinct autoimmune diseases were analyzed: 17 on Sjögren's syndrome (SS), 11 on oral lichen planus (OLP), 8 on Type 1 diabetes, 6 on rheumatoid arthritis (RA), 4 on systemic scleroderma (SSc), 3 on Crohn's disease (CD), 3 on systemic lupus erythematosus (SLE), 2 on mucous membrane pemphigoid (MMB) and 1 on pemphigus vulgaris (PV). Despite the heterogeneity and methodological limitations of most of the studies, results showed that dental implant survival rates were comparable to those reported in the general population. However, patients with secondary SS or erosive OLP were more susceptible to developing peri-mucositis and increased marginal bone loss.

CONCLUSION

This review suggested that dental implants may be considered as a safe and viable therapeutic option in the management of edentulous patients suffering from autoimmune diseases. Nevertheless, scrupulous maintenance of oral hygiene and long-term follow-up emerge as being the common determinants for uneventful dental implant treatment.

Buccal corticotomy using piezosurgery as a surgical approach for removal of deeply impacted mandibular teeth: An alternative procedure to avoid pitfalls associated with the conventional technique

PURPOSE

To describe and evaluate the use of buccal corticotomy (BC) using a piezosurgical approach for the removal of deeply impacted mandibular teeth.

PATIENTS AND METHODS

The charts of all patients who underwent BC for the removal of impacted mandibular teeth between 2011 and 2019 at the University Hospital of Geneva were reviewed. The primary outcome variables were (1) the indication for the removal of impacted mandibular teeth by BC, (2) complications. Other variables included age, gender, teeth involved, indication for tooth removal and radiological features. Follow-up was at 1, 3, 6 and 12 months, and we noted the status of healing and complications, if any.

RESULTS

Twenty-three mandibular-impacted teeth in 6 patients were extracted using BC (8 third molars, 6 second molars, 1 first molar, 4 second premolars and 4 first premolars). The indications for using the BC approach included (1) deeply impacted teeth closely related to the inferior alveolar nerve (IAN) that runs either lingually or inferior to the dental roots (4 patients); or (2) deeply impacted teeth closely related to the IAN and located anterior to the second molar region (2 patients). No complications were observed during the follow-up period.

CONCLUSION

The present study showed that the BC approach is a valuable method for removing deeply impacted teeth in close proximity to the mandibular canal and is associated with no complications and sound bone healing.

Posttraumatic Respiratory Epithelial Orbital Cyst With Intracranial Extension: A Unique Association

Respiratory epithelial orbital cysts (REOC) are rare benign lesions that may be either congenital or acquired. Congenital REOC develop from embryological epithelial rests and are known as choristomas, whereas acquired forms develop from the sequestration of respiratory epithelium from adjacent paranasal sinuses following trauma and/or fracture repair procedures. The final diagnosis can be difficult because congenital and acquired REOC and mucoceles share the same features histologically. The involvement of the paranasal sinuses, which is the landmark of mucoceles, does not occur with REOC. Moreover, the intracranial extension, which is known for mucoceles, has never been reported for REOC. Respiratory epithelial orbital cysts warrant prompt radical surgical resection given that these lesions may lead to a progressive intracranial progression and/or recurrent infection with a potential for meningitis or cerebral abscess. The authors report a unique case of a patient with an intraorbital posttraumatic respiratory epithelial orbital cyst associated with intracranial involvement.

[Orbital fractures: enigmatic and insidious entities]

Orbital fractures are frequent and can result in severe complications (visual impairment, diplopia and enophthalmos). Their management is challenging and remains controversial. Whereas immediate surgery is clearly indicated in children with trapdoor fractures associated with annoying diplopia and observational management is indicated in cases with no diplopia, a grey zone of therapy decisions concern a significant portion of cases. Surgical repair is not trivial and can be plagued by severe complications such as visual impairment, globe misplacement and diplopia. Thus, the final decision should be based on a meticulous analysis of clinical and imaging findings and a wise assessment of the risks and benefits of either therapeutic alternative.

Angiolymphoid Hyperplasia with Eosinophilia Located on the Forehead: A Possible Association with Oral Contraceptive Use?

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon benign vasoproliferative tumor characterized by nodules, papules or plaques localized principally in the head and neck region. Histopathological examination reveals hyperplastic blood vessels lined by large endothelial cells, accompanied by an infiltrate of inflammatory cells including eosinophils. The pathogenetic mechanism remains unclear, although different theories have been proposed. Various treatment strategies have been described, but surgery remains the treatment of choice. We describe the case of a young woman with ALHE taking an oral contraceptive pill suggesting a possible etiopathogenetic relationship.

Modified Le Fort I step osteotomy for improvement of paranasal flatness in maxillary deficiency: Technical note and series of 24 cases

INTRODUCTION

To describe a modified Le Fort I step osteotomy for the improvement of paranasal flatness in maxillary deficiency and to evaluate postoperative complications as well as post-treatment relapse.

PATIENTS AND METHODS

In this retrospective case series study, clinical data of all patients with maxillary deficiency associated with a Class III malocclusion who underwent a modified Le Fort I step osteotomy were reviewed. The primary and secondary outcome variables were, respectively, the improvement of paranasal flatness as evaluated by the clinical analysis of the cheekbone-nasal base-lip contour (CP-Nb-LC), and postoperative complications as well as post-treatment relapse. Other variables included age, gender, and additional surgical procedures. Descriptive statistics were performed.

RESULTS

The sample was composed of 24 patients. Paranasal flatness was corrected with the reestablishment of an harmonious convex cheekbone-nasal base-lip contour in all patients, who were satisfied with the esthetic result. Two patients (8%) had discomfort associated with the paranasal plates. One of these also had a unilateral nasolacrimal duct dysfunction with occasional bothersome epiphora that resolved after plate removal. Two patients (8%) had maxillary sinusitis that resolved rapidly following medical treatment. One patient (4%) had persistent minor infraorbital nerve hypoesthesia. No occlusal relapse or pseudarthrosis occurred.

CONCLUSION

The modified Le Fort I step osteotomy approach is a valuable method for the improvement of paranasal flatness in maxillary deficiency.

[Applications of maxillo-facial computer assisted surgery]

During the last two decades, computer-assisted surgery (CAS) has drastically changed the strategy for craniofacial reconstructive surgery, especially with respect to the prediction of preoperative virtual and ideal bone repositioning for correction of developmental or post-traumatic malformations. Intraoperative navigation and computer-aided design and modeling techniques (CAD/CAM) allow for the transfer of the virtual planned reconstruction to the operating room by guaranteeing a real time assistance during the realization of the surgical task and respectively by using patient-specific implants, surgical cutting and drilling guides. This approach has thus significantly contributed to improve the clinical accuracy, predictability and patient outcome, compared to traditional techniques.

Management of median and paramedian craniofacial clefts

BACKGROUND

Median and paramedian craniofacial clefts are associated with hypertelorism, anterior encephalocele, positional abnormalities of the maxilla, and nasal deformity. Cleft lip and palate, eyelid coloboma, and widow's peak are frequently present.

METHODS

The authors collected data from 30 patients (mean age, 5.8 years; range, 4 months to 18 years) operated between 1986 and 2017 with median or paramedian craniofacial clefts of differing degrees of severity. Malformations of the different anatomic units and their surgical treatment were assessed, as well as complication rates.

RESULTS

All patients presented nasal malformations and either telecanthus (n = 16) or hypertelorism (n = 14). Most patients (n = 23) had anterior encephalocele. All patients underwent nasal corrections, and most of them had medial canthopexy (n = 24). Excision of encephalocele was associated with fronto-orbital remodeling. Medialization of the orbits was performed in 11 patients, mainly by box shift (n = 9). Patients from outside Switzerland (n = 23) were operated at an older age than those in the native patient group. Because of staged reconstruction, 13 patients had more than one operation. Surgical complications included three infections and one expander exposition. One patient had bone resorption of a frontal bone flap. Nasal correction needed more than one procedure in 5 patients, and medial canthopexy had to be repeated in 7 patients. Esthetic results were satisfactory, permitting social integration.

CONCLUSION

Median and paramedian craniofacial clefts need adapted and carefully planned corrections respecting the growth of anatomic units. The quality of the medial canthal and nasal reconstruction is to a large extent responsible for the overall result.

Bilateral temporomandibular joint ankyloses after bilateral sagittal split osteotomy of the mandible: An uncommon clinical case with long-term outcome evaluation

Temporomandibular joint (TMJ) ankylosis is an extremely handicapping condition characterized by a permanent restriction in the ability to open the mouth, and it is mainly caused by traumatic and infectious events. It rarely occurs as a complication following orthognathic surgery. The treatment goals are the restoration of viable mandibular function and, in growing pediatric patients, symmetrical mandibular development. We are reporting here the unusual case of a bilateral bony TMJ ankylosis in a patient who underwent a bilateral sagittal split osteotomy of the mandible for correction of a mandibular deficiency. The patient was treated by bilateral arthrotomies with the interposition of a full-thickness skin graft as well as bilateral coronoidectomies with a favorable long-term (6 years) functional outcome. Only one similar case has been previously reported in the literature.

Is Preoperative Maintenance of the Curve of Spee Associated With an Increase of Facial Height in Class II Short Face Orthognathic Patients? A Never Answered Dogmatic Question

PURPOSE

To determine the association of maintaining the curve of Spee (COS) before surgery with post-treatment facial height in patients with Class II short face syndrome undergoing combined orthodontic and orthognathic treatment.

MATERIALS AND METHODS

In this retrospective cohort study, the clinical and radiologic data of all patients with Class II short face syndrome who underwent combined orthodontic and orthognathic treatment were reviewed. The primary outcome variables were 1) preoperative COS and 2) post-treatment facial height. Depth of the COS and skeletal and soft tissue relations were measured on digital lateral cephalometric radiographs. Descriptive and bivariate statistics were performed.

RESULTS

The sample was composed of 20 patients. Statistical analysis showed a significant increase of soft tissue facial height after treatment (P < .02). Preoperative depth of the COS was significantly associated with changes in sagittal skeletal relations (angle formed by the sella, nasion, and B point [SNB], correlation [cor] = -0.54, P < .02; angle formed by the A point, nasion, and B point [ANB], cor = 0.43, P < .06). These changes and changes in overjet were associated with the post-treatment increase of lower facial height (SNB, cor = 0.70, P < .001; ANB, cor = -0.69, P < .001; overjet, cor = -0.55, P < .049). The ratios of upper to lower soft tissue facial height and upper to lower lip height were improved to near normal values (1.0 and 0.5, respectively) for most patients.

CONCLUSION

In patients with Class II short face orthognathism, the present study found that maintaining the COS before surgery was associated with 1) an increase of soft tissue facial height and 2) an improvement of the ratio of upper to lower facial height and the ratio of upper to lower lip height to near normal values. Moreover, the depth of the COS was correlated with the post-treatment increase of facial height through changes in skeletal relations and was related to the degree of severity of the mandibular deficiency.

Streptococcus anginosus Dental Implant-Related Osteomyelitis of the Jaws: An Insidious and Calamitous Entity

PURPOSE

We analyzed the data from a series of patients with dental implant-related suppurative osteomyelitis of the jaws (DIOMJ) due to Streptococcus anginosus.

PATIENTS AND METHODS

The medical records of all patients seen for osteomyelitis of the jaws from 2011 to 2016 were reviewed. The primary outcome variable was Streptococcus anginosus DIOMJ. Other variables included age, gender, smoking habits, associated comorbidities, dental implant localization, type of osteomyelitis, delay between dental implant placement and DIOMJ, microbiologic examination and antibiogram, antibiotherapy, type of surgery, and final outcome. Cases from previous reports of DIOMJ were also analyzed for comparison. Finally, descriptive statistics were computed.

RESULTS

A total of 26 patients had jaw osteomyelitis; in 6 patients (26%), jaw osteomyelitis had developed after dental implant placement. S. anginosus was found in 5 patients and Escherichia coli in 1. The osteomyelitis was located in the mandible and associated with a deep neck abscess in all cases. All the patients were women and were either smokers or had comorbidities affecting bone metabolism. In all 6 cases, the dental implants were removed, and several surgical debridement procedures (≥2) and prolonged antibiotherapy (average of 6 months) were needed. Of the 6 patients, 3 required a radical surgical reconstructive procedure with partial resection and bone grafting.

CONCLUSIONS

The present study demonstrated that Streptococcus anginosus DIOMJ is a particularly aggressive form of osteomyelitis that has a propensity to develop in the mandible of women in their 60s who are either smokers or have comorbidities.

Benefit of Temporomandibular Joint Lavage With Intra-Articular Steroids Versus Lavage Alone in the Management of Temporomandibular Joint Involvement in Juvenile Idiopathic Arthritis

PURPOSE

The aim of the present investigation was to evaluate, in patients with juvenile idiopathic arthritis, the effect of lavage with or without intra-articular corticosteroid (IACS) injection on clinical temporomandibular joint (TMJ) signs and symptoms of inflammation and changes in acute inflammation as assessed using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Forty-one patients (mean age, 13.6 ± 4.0 yr) with juvenile idiopathic arthritis participating in a large prospective juvenile inflammatory rheumatism cohort study (JIRcohorte) were included in this study. Clinical history, examination, and MRI were carried out at baseline and 6 months after intervention, if any. Twenty-one patients underwent lavage and IACS injection in at least 1 TMJ, 8 patients underwent lavage of at least 1 TMJ, and 12 patients were followed with no intervention. Outcomes measured were maximal mouth opening, Helkimo dysfunction index scores, pain intensity, and acute inflammation as assessed using MRI.

RESULTS

All groups showed a mean increase in mouth opening and mean decrease in pain intensity. The mean Helkimo clinical dysfunction score decreased for the 2 intervention groups but not for the control group. The mean Helkimo anamnestic dysfunction score decreased for the lavage with IACS group but not for the lavage-only group. The only statistically relevant difference was found for the Helkimo anamnestic dysfunction score comparing the lavage-only with the lavage with IACS group, with a more positive effect found in the lavage with IACS group. More than 50% of joints in each group showed no change at MRI examination. Joints with lavage and ICAS injection showed better improvement than joints that had lavage only or no intervention.

CONCLUSION

TMJ lavage with or without IACS injection cannot be claimed to systematically decrease pain, increase mouth opening, or resolve acute inflammation. Despite a tendency for improvement, response to this treatment is very patient dependent and can be determined by an array of other variables.

Bone Recontouring by Guided Surgical Navigation Integrating “Mirroring” Computational Planning in the Management of Severe Fronto-orbital Asymmetry in Fibrous Dysplasia

We report the successful treatment of severe fronto-orbital asymmetry in a 20-year-old man with fibrous dysplasia by bone recontouring using a specific approach combining “mirroring” virtual computational planning with intraoperative guided surgical navigation.

Facial Nerve Injury and Other Complications Following Retromandibular Subparotid Approach for the Management of Condylar Fractures

PURPOSE

To estimate the prevalence and identify risk factors for facial nerve paralysis (FNP) and other postoperative complications after the use of the retromandibular subparotid approach (RMSA) for the treatment of condylar fractures.

MATERIALS AND METHODS

Radiologic and clinical data from all patients who underwent an RMSA from 2007 through 2015 at the University Hospital of Geneva (Geneva, Switzerland) were retrospectively reviewed. The primary and secondary outcome variables were, respectively, FNP and other complications (unesthetic scars, infection, nonunion, malocclusion, salivary fistula, Frey syndrome, and loosening or breaking of plates and screws). Predictor variables included age, gender, mechanism of injury, delay from injury to surgery, surgeon's experience, location of fracture, side and pattern of fracture, concomitant facial fractures, and status of healing. Univariable logistic regression statistics were computed.

RESULTS

Forty-eight subcondylar fractures in 43 consecutive patients were treated using the RMSA. Six fracture sites (12.5%) developed a temporary FNP that completely resolved within 4 months. Fractures at the neck level and with the comminution pattern were significant risk factors of postoperative FNP (P = .04 and P < .001, respectively; odds ratio = 82). Eight patients (18.6%) developed a slight transient malocclusion that was completely corrected within 3 to 4 weeks using guiding elastics and 1 patient (2.3%) had a wound dehiscence that resolved with a visible but thin and linear scar.

CONCLUSION

The present study showed that 1) the FNP rate after the RMSA to surgery for condylar fractures was similar to that reported after the transparotid variant; 2) the FNP was transient and completely resolved in all patients; 3) neck and comminuted condylar fractures were statistically associated with increased risk of developing a postoperative temporary FNP; and 4) the final outcome was favorable with no major complications in any of the patients.

Is Atypical Swallowing Associated With Relapse in Orthognathic Patients? A Retrospective Study of 256 Patients

PURPOSE

To determine the association of atypical swallowing (AS) with relapse in patients undergoing combined orthodontic and orthognathic treatment.

MATERIALS AND METHODS

In this retrospective cohort study, the clinical data of all patients who underwent combined surgical and orthodontic treatment from 1998 through 2015 at the University Hospital of Geneva (Geneva, Switzerland) were reviewed. The primary outcome variables were 1) AS and 2) post-treatment relapse. Other variables included, age, gender, dentofacial deformity (facial asymmetry, mandibular deficiency, mandibular excess, maxillary retrusion, open bite), surgical procedure performed (bilateral sagittal split osteotomy [BSSO] with or without Le Fort I osteotomy), and dental interocclusal relations according to Angle.

RESULTS

Of the 256 patients investigated, 23 (9%) showed relapse at 1 year after treatment. Multivariate analysis showed that AS status (before treatment, odds ratio [OR] = 9.44, P = .005; after treatment, OR = 56.17, P < .001; before and after treatment, OR = 20.49, P < .001) was significantly associated with relapse. The presence of a pretreatment open bite also was associated with an increased risk of relapse (OR = 0.04, P < .001) regardless of AS status.

CONCLUSION

The present study showed that in orthognathic patients 1) AS was associated with relapse regardless of dentofacial deformity or surgical procedure performed and 2) AS can appear after treatment in patients who were initially free of it.

Removal of recurrent intraorbital tumour using a system of augmented reality

The most crucial step in the management of pleomorphic adenoma of the lacrimal gland is choosing the optimal approach for excision. We report the successful removal of a recurrent pleomorphic adenoma of the lacrimal gland in a 42-year-old woman using a specific microscope-based system of augmented reality.

Computer-Assisted Virtual Planning for Surgical Guide Manufacturing and Internal Distractor Adaptation in the Management of Midface Hypoplasia in Cleft Patients

We are reporting the treatment of severe maxillary hypoplasia in two patients with unilateral cleft lip and palate by using a specific approach combining the Le Fort I distraction osteogenesis technique coupled with computer-aided design/computer-aided manufacturing customized surgical guides and internal distractors based on virtual computational planning. This technology allows for the transfer of the virtual planned reconstruction to the operating room by using custom patient-specific implants, surgical splints, surgical cutting guides, and surgical guides to plate or distractor adaptation.

Clinical predictive factors for temporomandibular disorders following combined orthodontic and orthognathic surgical treatment in patients with Class III malocclusion

OBJECTIVE

The aim of this study was to identify clinical factors predisposing to the development or worsening of temporomandibular disorders (TMDs) following orthodontic surgical treatment for Class III malocclusion.

METHODS

A retrospective cohort study was performed on 88 patients with Class III malocclusion having undergone a combined orthodontic and orthognathic surgical treatment. Temporomandibular joint and masticatory muscle examinations were available prior to treatment and one year post-operatively. Multivariate logistic regression was used to predict the development of post-operative TMDs, and linear regression was used to predict the worsening of TMDs using Helkimo indices.

RESULTS

Patients with Class III malocclusion presenting with pre-treatment anamnestic TMJ clicking (OR = 5.8; p = 0.03) and undergoing bimaxillary osteotomy procedures (OR = 18.6; p = 0.04) were more at risk for the development of TMDs.

DISCUSSION

TMDs must be evaluated, monitored, and managed with caution in patients with Class III malocclusion presenting with pre-treatment joint clicking and who are planned for bimaxillary osteotomies.

Comparison of the incidence of osteoradionecrosis with conventional radiotherapy and intensity-modulated radiotherapy

BACKGROUND

Modern techniques of radiotherapy are supposed to decrease the incidence of osteoradionecrosis of the mandible (ORNM). The purpose of this study was to compare the incidence of ORNM after intensity-modulated radiotherapy (IMRT) in comparison to conventional 3D conformal radiotherapy techniques (conventional RT).

METHODS

We conducted a retrospective study of consecutive unselected patients treated in a single institution between 2002 and 2012. To minimize confounding effects, only patients with oropharyngeal carcinoma without surgery of the primary site were included.

RESULTS

The cohorts included 145 patients in the conventional RT group and 89 patients in the IMRT group. Total incidence rate of ORNM was similar for both groups with rates of 11% versus 10% (n = 16 for conventional RT and n = 9 for IMRT; p = 1.0). Subanalysis revealed more ORNM in T4 classified lesions with IMRT (p = .007). Analysis of different risk factors showed no statistically significant difference between ORNM and no-ORNM patients.

CONCLUSION

We found no reduction in ORNM with IMRT. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Are condylar morphologic changes associated with temporomandibular disorders in patients with orthognathia?

OBJECTIVE

To determine the association between morphologic condylar changes and temporomandibular disorders (TMDs) in patients with orthognathia.

STUDY DESIGN

Data from 89 patients were analyzed. TMDs were classified according to the Research Diagnostic Criteria for TMDs. TMD severity was scored according to the Helkimo indices. Calculation of the condylar area, perimeter, and height was performed by using a specific computational method including panoramic radiography.

RESULTS

Sixty-five (73%) patients presented with morphologic condylar changes. Decreases in condylar perimeter and area were found to be predictors of postoperative TMDs (P = .009; odds ratio [OR] = 3.66) and disk displacement (P = .008; OR = 4.43), respectively. Condylar area and height decreases were associated with worsening of TMDs (P = .03 and 0.04).

CONCLUSIONS

This study demonstrated that in orthognathic patients, postoperative condylar changes are associated with postoperative TMDs as well as with the degree of TMD severity and that preoperative TMDs are associated with such condylar changes.

Association between maxillary sinus fungus ball and sinus bone grafting with deproteinized bovine bone substitutes: a case-control study

OBJECTIVE

To evaluate the association between sinus bone graft and the development of fungus ball (FB) of the maxillary sinus.

STUDY DESIGN

The charts of all patients seen for surgical treatment of maxillary sinus FB following sinus bone grafting between 2006 and 2014 were reviewed. The charts of 49 participants were selected from our internal registry for comparison as controls. The association between FB and age, gender, smoking habits, associated co-morbidities, and bone grafting material was evaluated. FB of the maxillary sinus was estimated by using an odds ratio with a Yates' correction. P values were computed using Fisher's exact test, and the statistical significance was set at a P value < .05.

RESULTS

All 13 cases (100%) with FB of the maxillary sinus had received anorganic bovine bone as the bone substitute (P = .0001). There were significantly more women in the case group than in the control group (84.6% in the cases vs 40.8% in the controls; P = .01).

CONCLUSIONS

This study demonstrated a significant association between a specific deproteinized bovine bone substitute use as sinus bone graft material and subsequent development of FB of the maxillary sinus.

[Burning mouth syndrome - a joint biopsychosocial approach]

Burning mouth syndrome (BMS) is a medical condition that is often refractory to conventional diagnostic and therapeutic methods. Patients suffering from BMS can benefit from a biopsychosocial approach in a joint, medical-psychological consultation model. Such a consultation exists at Geneva University Hospitals, involving the collaboration of the maxillo-facial and oral surgery division and the division of liaison psychiatry and crisis intervention, in order to take into account the multiple factors involved in BMS onset and persistence. This article will describe BMS clinical presentation, and present an integrate approach to treat these patients.

Computer-aided design and computer-aided modeling (CAD/CAM) generated surgical splints, cutting guides and custom-made implants: Which indications in orthognathic surgery?

INTRODUCTION

The purpose of the present report was to describe our indications, results and complications of computer-aided design and computer-aided modeling CAD/CAM surgical splints, cutting guides and custom-made implants in orthognathic surgery.

PATIENTS AND METHODS

We analyzed the clinical and radiological data of ten consecutive patients with dentofacial deformities treated using a CAD/CAM technique. Four patients had surgical splints and cutting guides for correction of maxillomandibular asymmetries, three had surgical cutting guides and customized internal distractors for correction of severe maxillary deficiencies and three had custom-made implants for additional chin contouring and/or mandibular defects following bimaxillary osteotomies and sliding genioplasty. We recorded age, gender, dentofacial deformity, surgical procedure and intra- and postoperative complications.

RESULTS

All of the patients had stable cosmetic results with a high rate of patient satisfaction at the 1-year follow-up examination. No intra- and/or postoperative complications were encountered during any of the different steps of the procedure.

DISCUSSION

This study demonstrated that the application of CAD/CAM patient-specific surgical splints, cutting guides and custom-made implants in orthognathic surgery allows for a successful outcome in the ten patients presented in this series.

Accuracy evaluation of CAD/CAM generated splints in orthognathic surgery: a cadaveric study

Introduction

To evaluate the accuracy of CAD/CAM generated splints in orthognathic surgery by comparing planned versus actual post-operative 3D images.

Methods

Specific planning software (SimPlant^® OMS Standalone 14.0) was used to perform a 3D virtual Le Fort I osteotomy in 10 fresh human cadaver heads. Stereolithographic splints were then generated and used during the surgical procedure to reposition the maxilla according to the planned position. Pre-operative planned and postoperative 3D CT scan images were fused and imported to dedicated software (MATLAB^®) 7.11.) for calculating the translational and rotational (pitch, roll and yaw) differences between the two 3D images. Geometrical accuracy was estimated using the Root Mean Square Deviations (RMSD) and lower and upper limits of accuracy were computed using the Bland & Altman method, with 95 % confidence intervals around the limits. The accuracy cutoff was set at +/− 2 mm for translational and ≤ 4° for rotational measurements.

Results

Overall accuracy between the two 3D images was within the accuracy cutoff for all values except for the antero-posterior positioning of the maxilla (2.17 mm). The translational and rotational differences due to the splint were all within the accuracy cutoff. However, the width of the limits of agreement (range between lower and upper limits) showed that rotational differences could be particularly large.

Conclusion

This study demonstrated that maxillary repositioning can be accurately approximated and thus predicted by specific computational planning and CAD/CAM generated splints in orthognathic surgery. Further study should focus on the risk factors for inaccurate prediction.

[Toothache: At what point has a pontocerebellar angle tumor to be evoked?]

INTRODUCTION

Dental pain may have another origin than teeth. It may be caused by myofascial, neurovascular, cardiac, neurological, sinusal or psychological factors. We will discuss 2 rare cases of patients who presented with a cerebellopontine tumor, who initially manifested with symptoms of dental pain.

OBSERVATION

The first patient, male, 44 years of age presented to his dentist with toothache (47), which led to its extraction. Five months later, a second painful episode, more characteristic, revealed the presence of a vestibular schwannoma, which was successfully treated and led to the disappearance of the pain. The second case, a 43-year-old female presented to her dentist with toothache (46), which lead the dentist perform a root filling. Two years later, with a 3rd episode of dental pain, more relevant of a trigeminal neuralgia, a epidermoid cyst of the right cerebellopontine angle was identified and successfully treated leading to the disappearance of the pain.

DISCUSSION

Cerebellopontine tumors of this type may lead, in exceptional cases to symptoms of dental pain. Therefore, in face of atypical tooth or facial pain, both a detailed medical history and a detailed examination are necessary, in order to investigate any neurological signs and symptoms, before undertaking any non-essential dental treatment, which may be detrimental for the patients.

Can clinical factors predict postoperative temporomandibular disorders in orthognathic patients? A retrospective study of 219 patients

OBJECTIVE

To determine the predictive value of preoperative clinical factors for postoperative temporomandibular disorders (TMDs) in patients receiving combined surgical-orthodontic treatment.

STUDY DESIGN

TMDs were classified according to Research Diagnostic Criteria for TMD in 219 patients. The severity of the TMD was scored according to the Helkimo anamnestic index (Ai) and clinical dysfunction index (Di).

RESULTS

Anamnestic TMJ clicking was the only significant predictor of TMD (odds ratio [OR] = 3.61, P = .006). The mean difference between clinical dysfunction index points was significant for pain on masticatory muscle palpation.

CONCLUSION

This study demonstrated that in orthognathic patients, the following factors had high predictive value: (1) anamnestic TMJ clicking for TMD, (2) TMJ clicking, TMJ pain on palpation and bimaxillary surgery for Ai worsening, (3) maxillary retrusion and mandibular excess for Ai improvement, and (4) pain on masticatory muscle palpation for Di worsening.

Accuracy of computational soft tissue predictions in orthognathic surgery from three-dimensional photographs 6 months after completion of surgery: a preliminary study of 13 patients

BACKGROUND

This study aimed at a preliminary evaluation of the accuracy of computed three-dimensional (3D) predictions in orthognathic surgery by comparing predicted and real postoperative results.

METHODS

Pre- and postoperative 3D photographs and time-matching computed tomography (CT) and cone-beam CT scans of the face of 13 patients with dentofacial deformities were analyzed. Three-dimensional photographs were fused with preoperative CT data using dedicated software (3dMDvultus, version 2.2.0.8). Postoperative CT data were superposed on the preoperative skull. With an activated rendering function, the osteotomies were simulated in the preoperative CT data and the bony segments moved to their real postoperative position, resulting in a textured soft tissue prediction. This computed skin surface was compared with the real postoperative result by dividing the face into a surgically treated lower half and an untreated upper half. A statistical quantitative analysis of the surfaces was performed.

RESULTS

The mean differences between surfaces were +0.27 mm for the untreated upper half and -0.64 mm for the surgically treated lower half (p < 0.001). Averaged distributions of absolute errors showed more discrepancies between predicted and real postoperative results in the lower half of the face. Errors exceeding 3 mm were encountered in 4 % of the upper halves versus 29.8 % of the lower halves (p < 0.001).

CONCLUSIONS

The accuracy of a specific software platform for predicting 3D soft tissue changes after surgery was insufficient.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Radiolucent lesions of the mandible: a pattern-based approach to diagnosis

Objectives

Radiolucent mandibular lesions seen on panoramic radiographs develop from both odontogenic and non-odontogenic structures. They represent a broad spectrum of lesions with a varying degree of malignant potential. The purpose of this review is to illustrate the characteristic imaging findings—as well as the clinical and histological features—of common and uncommon radiolucent lesions of the mandible.

Methods

This review article is based on the retrospective evaluation of 11,725 panoramic radiographs seen in our institution during the past 6 years. It provides a comprehensive, practical approach to the radiological interpretation of radiolucent lesions of the mandible. To facilitate the diagnostic approach, we have classified radiolucent lesions into two groups: lesions with well-defined borders and those with ill-defined borders.

Results

Lesion prevalence, age of manifestation, location within the mandible, relationship to dental structures, effect on adjacent structures and characteristic findings at computed tomography (CT), cone beam CT (CBCT) and magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) are discussed. Pitfalls including malignant lesions mimicking benign disease and pseudo-lesions are equally addressed.

Conclusion

Knowledge of the characteristic imaging features of radiolucent mandibular lesions narrows the differential diagnosis and is crucial for the identification of those lesions, where biopsy is indicated for definitive histology.

Teaching points

• Panoramic X-rays, CT and MRI are essential for the work-up of radiolucent mandibular lesions.

• Lesion borders, location within the mandible, relationship to dental structures and tissue characteristics on cross-sectional imaging are indispensable to narrow the differential diagnosis.

• High-resolution CT and CBCT play a major role for the assessment of lesion margins and their relationship to important anatomic structures, such as the inferior alveolar nerve.

• Although most radiolucent lesions with well-defined sclerotic borders are benign, MRI may reveal clinically unsuspected malignant disease.