Management of isolated mandibular body fractures in adults

Objective@#The mandible is the most common fractured craniofacial bone of all craniofacial fractures in the Philippines, with the mandibular body as the most involved segment of all mandibular fractures. To the best of our knowledge, there are no existing guidelines for the diagnosis and management of mandibular body fractures in particular. General guidelines include the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAOHNSF) Resident Manual of Trauma to the Face, Head, and Neck chapter on Mandibular Trauma, the American Association of Oral and Maxillofacial Surgeons (AAOMS) Clinical Practice Guidelines for Oral and Maxillofacial Surgery section on the Mandibular Angle, Body, and Ramus, and a 2013 Cochrane Systematic Review on interventions for the management of mandibular fractures. On the other hand, a very specific Clinical Practice Guideline on the Management of Unilateral Condylar Fracture of the Mandible was published by the Ministry of Health Malaysia in 2005. Addressing the prevalence of mandibular body fractures, and dearth of specific guidelines for its diagnosis and management, this clinical practice guideline focuses on the management of isolated mandibular body fractures in adults.@*Purpose@#This guideline is meant for all clinicians (otolaryngologists – head and neck surgeons, as well as primary care and specialist physicians, nurses and nurse practitioners, midwives and community health workers, dentists, and emergency first-responders) who may provide care to adults aged 18 years and above that may present with an acute history and physical and/or laboratory examination findings that may lead to a diagnosis of isolated mandibular body fracture and its subsequent medical and surgical management, including health promotion and disease prevention. It is applicable in any setting (including urban and rural primary-care, community centers, treatment units, hospital emergency rooms, operating rooms) in which adults with isolated mandibular body fractures would be identified, diagnosed, or managed. Outcomes are functional resolution of isolated mandibular body fractures; achieving premorbid form; avoiding use of context-inappropriate diagnostics and therapeutics; minimizing use of ineffective interventions; avoiding co-morbid infections, conditions, complications and adverse events; minimizing cost; maximizing health-related quality of life of individuals with isolated mandibular body fracture; increasing patient satisfaction; and preventing recurrence in patients and occurrence in others.@*Action Statements@#The guideline development group made strong recommendationsfor the following key action statements: (6) pain management- clinicians should routinely evaluate pain in patients with isolated mandibular body fractures using a numerical rating scale (NRS) or visual analog scale (VAS); analgesics should be routinely offered to patients with a numerical rating pain scale score or VAS of at least 4/10 (paracetamol and a mild opioid with or without an adjuvant analgesic) until the numerical rating pain scale score or VAS is 3/10 at most; (7) antibiotics- prophylactic antibiotics should be given to adult patients with isolated mandibular body fractures with concomitant mucosal or skin opening with or without direct visualization of bone fragments; penicillin is the drug of choice while clindamycin may be used as an alternative; and (14) prevention- clinicians should advocate for compliance with road traffic safety laws (speed limit, anti-drunk driving, seatbelt and helmet use) for the prevention of motor vehicle, cycling and pedestrian accidents and maxillofacial injuries.The guideline development group made recommendations for the following key action statements: (1) history, clinical presentation, and diagnosis - clinicians should consider a presumptive diagnosis of mandibular fracture in adults presenting with a history of traumatic injury to the jaw plus a positive tongue blade test, and any of the following: malocclusion, trismus, tenderness on jaw closure and broken tooth; (2) panoramic x-ray - clinicians may request for panoramic x-ray as the initial imaging tool in evaluating patients with a presumptive clinical diagnosis; (3) radiographs - where panoramic radiography is not available, clinicians may recommend plain mandibular radiography; (4) computed tomography - if available, non-contrast facial CT Scan may be obtained; (5) immobilization - fractures should be temporarily immobilized/splinted with a figure-of-eight bandage until definitive surgical management can be performed or while initiating transport during emergency situations; (8) anesthesia - nasotracheal intubation is the preferred route of anesthesia; in the presence of contraindications, submental intubation or tracheostomy may be performed; (9) observation - with a soft diet may serve as management for favorable isolated nondisplaced and nonmobile mandibular body fractures with unchanged pre - traumatic occlusion; (10) closed reduction - with immobilization by maxillomandibular fixation for 4-6 weeks may be considered for minimally displaced favorable isolated mandibular body fractures with stable dentition, good nutrition and willingness to comply with post-procedure care that may affect oral hygiene, diet modifications, appearance, oral health and functional concerns (eating, swallowing and speech); (11) open reduction with transosseous wiring - with MMF is an option for isolated displaced unfavorable and unstable mandibular body fracture patients who cannot afford or avail of titanium plates; (12) open reduction with titanium plates - ORIF using titanium plates and screws should be performed in isolated displaced unfavorable and unstable mandibular body fracture; (13) maxillomandibular fixation - intraoperative MMF may not be routinely needed prior to reduction and internal fixation; and (15) promotion - clinicians should play a positive role in the prevention of interpersonal and collective violence as well as the settings in which violence occurs in order to avoid injuries in general and mandibular fractures in particular.

Genetic polymorphisms in NAT1, NAT2, GSTM1, GSTP1 and GSTT1 and susceptibility to colorectal cancer among Filipinos

@#Objectives. Polymorphisms in metabolic genes which alter rates of bioactivation and detoxification have been shown to modulate susceptibility to colorectal cancer. This study sought to evaluate the colorectal cancer risk from environmental factors and to do polymorphism studies on genes that code for Phase I and II xenobiotic metabolic enzymes among Filipino colorectal cancer patients and matched controls. Methods. A total of 224 colorectal cancer cases and 276 controls from the Filipino population were genotyped for selected polymorphisms in GSTM1, GSTP1, GSTT1, NAT1 and NAT2. Medical and diet histories, occupational exposure and demographic data were also collected for all subject participants.Results. Univariate logistic regression of non-genetic factors identified exposure to UV (sunlight) (OR 1.99, 95% CI: 1.16-3.39) and wood dust (OR 2.66, 95% CI: 1.21-5.83) and moldy food exposure (OR 1.61, 95% CI:1.11-2.35) as risk factors; while the NAT2*6B allele (recessive model OR 1.51, 95% CI :1.06-2.16; dominant model OR 1.87, 95% CI: 1.05-3.33) and homozygous genotype (OR 2.19, 95% CI: 1.19-4.03) were found to be significant among the genetic factors. After multivariate logistic regression of both environmental and genetic factors, only UV radiation exposure (OR 2.08, 95% CI: 1.21-3.58) and wood dust exposure (OR 2.08, 95% CI: 0.95-5.30) remained to be significantly associated with increasing colorectal cancer risk in the study population.Conclusion. This study demonstrated that UV sunlight and wood dust exposure play a greater role in influencing colorectal cancer susceptibility than genotype status from genetic polymorphisms of the GST and the NAT` genes.

The prevalence of CYP2D6 Gene Polymorphisms among Filipinos and their use as biomarkers for lung cancer risk

Objectives@#The highly polymorphic nature of the CYP2D6 gene and its central role in the metabolism of commonly used drugs make it an ideal candidate for pharmacogenetic screening. This study aims to determine the prevalence of CYP2D6 polymorphisms among Filipinos and their association to lung cancer. @*Method@#Forty seven single nucleotide polymorphisms (SNPs) of the CYP2D6 gene were genotyped from DNA samples of 115 cases with lung cancer and age- and sex-matched 115 controls. @*Results@#Results show that 18 out of 47 polymorphisms have significant genotypic variability (>1% for at least 2 genotypes). No variant is associated with lung cancer. However, rs1135840, rs16947 and rs28360521, were found to be highly variable among Filipinos. @*Conclusion@#This study demonstrated that CYP2D6 polymorphisms are present among Filipinos, which, although not found to be associated with lung cancer, can be useful biomarkers for future pharmacogenetic studies. The SNP rs16947 is found to be associated with cancer and timolol-induced bradycardia; the SNP rs1135840, on the other hand, is only shown to be linked with cancer. The genetic variant rs28360521 is known to be associated with low-dose aspirin-induced lower gastrointestinal bleeding.

Gap arthroplasty of bilateral temporomandibular joint ankylosis

@#OBJECTIVES: To present a case of bilateral temporomandibular joint ankylosis that was managed successfully through gap arthroplasty. METHODS: Design: Case Report Setting: Tertiary Government Hospital Patient: One RESULTS:A 25-year-old man presented with inability to open his mouth for 18 years after direct trauma to his chin. CT scan showed bilateral bony fusion of condyles to glenoid fossae, hypertrophic sclerosis and fusion of the condylar heads to the temporal bones. He underwent bilateral gap arthroplasty via preauricular approach with creation of a 15 mm space on the mandibular fossa. As of latest follow up, the patient maintained an inter-alveolar distance of 30 mm for five months postoperatively through continuous aggressive mouth opening exercises. CONCLUSION:Gap arthroplasty may be an efficient procedure for temporomandibular joint ankylosis in achieving satisfactory post-operative inter-alveolar opening and articular function. Early and meticulous rehabilitation is required to prevent relapse. Long-term follow up is recommended to document possible recurrence.

Combination of autologous platelet-rich fibrin and bone graft: An invaluable option for reconstruction of segmental mandibular defects

@#Dear Editor, Reconstruction of mandibular defects resulting from ablative surgery for benign and malignant tumors remains a reconstructive challenge. For the past decade, the fibular free flap has been the workhorse for large mandibular defects because of its length, versatility, and ability to be harvested with a skin paddle for soft tissue closure. Although its success rate has continuously improved to almost 95%, donor site morbidity remains a matter of concern.1,2 Bone grafts are already widely used in dental surgery but only as fillers for chipped or marginal defects and not for large segmental mandibular defects. We present a new technique of reconstructing segmental mandibular defects using bone grafts combined with autologous platelet-rich fibrin (PRF), a biomaterial derived intra-operatively from the patient that incorporates leukocytes, platelets, growth factors, and a wide range of glycoproteins in a dense fibrin matrix. Moreover, we describe the essential role of PRF in bone healing and regeneration that offers an invaluable reconstructive option that is free of donor site morbidity without sacrificing the main goal of reconstruction in restoring both form and function.

New technique of occlusal splint fabrication using dental modeling compound

INTRODUCTION: The restoration of function after surgery with mandibular reconstruction is of utmost importance. Mastication and deglutition are compromised if pre-operative dental occlusion is not reestablished. For this purpose, occlusal splints are fabricated pre-operatively. Various methods of occlusal splint fabrication are at hand. DESIGN: Surgical Instrumentation SETTING: Tertiary Academic Hospital OBJECTIVE: This paper presents a simple, quick and inexpensive way of fabricating an occlusal splint with the use of dental modeling compound. MATERIALS AND METHODS: The dental modeling compound is used pre-operatively to make an occlusal appliance. Occlusal splint fabricated with this method was used in 6 patients who underwent segmental mandibular resection with reconstruction for various pathologies. Post-operatively, patients were assessed in terms of occlusion, type of diet and pain on mastication. RESULTS: Out of the 6 patients, only 5 patients were available for evaluation. One patient suffered a myocardial infarction 3 days post-operation and subsequently died. The five patients had good mandibular-maxillary relation post-surgery. They were able to tolerate regular diet with no pain on mastication. CONCLUSION: In conclusion, we have discussed a simple, quick and cost-effective way of fabricating an occlusal splint for use in mandibular reconstruction. (Author)

Condylar autograft with fibular free flap for mandibular reconstruction

DESIGN: Surgical Innovation SETTING: Academic Tertiary Hospital OBJECTIVE: The objective of the study was to describe an alternative technique using a condylar autograft in conjunction with a fibular free flap in mandibular reconstruction and to prospectively assess the functional outcome in terms of inter-incisal distance, lateral excursion, maximum protrusion, occlusion, type of diet, speech and mandibular contour. METHODOLOGY: All patients who underwent segmental mandibulectomy with fibular free flap reconstruction done by one microvascular team from 1997 to 2004 were reviewed. From a total of 38 patients who underwent fibular free flap reconstruction, 7 patients who had condylar disarticulation, rigid fixation using miniplates to the fibula then replacement into the glenoid fossa were identified but 2 patients were excluded due to poor follow-up. Functional outcomes in terms of inter-incisal distance, lateral excursion, maximum protrusion, occlusion, type of diet, speech and mandibular contour were assessed post-operatively. Presence of tumor recurrence was also noted. RESULTS: Five patients were included in the study. The inter-incisal distance was noted to be 31 mm (+/- 12.5) with maximum protrusion of 1.4 mm (+/- 0.9). For those with right hemimandibulectomy (n=2), the right lateral excursion was 2.34mm (+/- 3.3) and left lateral excursion was 1.66mm (+/- 2.35). For those with left hemimandibulectomy (n=3), the right lateral excursion was 8.17m (+/- 2.25) and left lateral excursion was 3 mm (+/- 2.65). Four out of 5 patients had normal diet with excellent intelligible speech. The same 4 patients had good mandibular contour with a Class I occlusion as assessed by a dentist. The only patient with fair outcome had a mucoepidermoid carcinoma of the floor of the mouth with extensive soft tissue reconstruction aside from the bony reconstruction. No patient had tumor recurrence. CONCLUSION: The use of condylar autograft in conjunction with fibular free flaps holds promise as a way to restore temporomandibular function in mandibular reconstruction. (Author)

Head and neck reconstruction using free flaps

BACKGROUND: Free flap reconstruction was first introduced in 1959 and has since been used for reconstruction of various defects in the head and neck. It has been shown to be the most reliable and efficient way of restoring tissue in the head and neck region secondary to surgical or traumatic defects. It has allowed single stage reconstruction of even complex defects with high flap viability rates. Here in the Philippine setting, free flaps have not been the reconstructive option of choice. It is viewed as a special option for selective cases not amenable to pedicled reconstruction. OBJECTIVE: To describe the experience of one microvascular team in head and neck reconstruction using free flaps from 1996 to March 2004. DESIGN AND SETTING: Retrospective chart review of all patients who underwent free flap reconstruction of head and neck defects from 1996 to March 2004 at six tertiary hospitals in Manila. PATIENTS AND METHODS: Atotal of 69 patients who underwent 71 free-flap reconstructions of the head and neck for various pathologies and with a range of bony and soft tissue defects from 1996 to March 2004 were included in the study. All free flap reconstructions were done by only one microvascular team. The success and viability of free tissue transfer, length of hospital stay, length of operation, complications and morbidities encountered and functional outcome based on length of time to removal of the nasogastric tube and decannulation were reviewed. RESULTS: Of the 71 free flap reconstructions that were performed, 64 flaps were viable leading to an overall success rate of 90 percent. The first 36 cases had a success rate of 86 percent while the subsequent 35 cases had a success rate of 94 percent. Average length of hospital stay was 24 days and the average length of operation was 13 hours 40 minutes. There were 6 mortalities secondary to medical problems and 7 patients had major surgical complications. Twenty-one patients (29 percent) did not have any complication post-operation. Average time post-operation to decannulation was 14 days while return to oral diet was noted at 17 days post-operation. There were 8 patients who were discharged with either a nasogastric tube or percutaneous endoscopic gastrostomy. The results are at par with the review of literature reviewed. CONCLUSIONS: The success of the use of free flaps in head and neck reconstruction was demonstrated in this series. There were minimal complications noted. All patients were decannulated with majority able to return to an oral diet. (Author)