Are embrasure wires better than arch bars for intermaxillary fixation?

PURPOSE: To compare the outcomes of mandible fractures treated with open reduction and internal fixation versus adjunctive intermaxillary fixation (IMF) using 2 different techniques. MATERIALS AND METHODS: We performed a retrospective medical record review. The medical records of consecutive patients with mandible fractures treated surgically with adjunctive use of IMF (embrasure wires vs arch bars) were reviewed for demographic data, etiology, fracture location, antibiotic use, and interval to repair. Specifically, the complications, including infection, malunion or nonunion, hardware failure, and wound dehiscence, were recorded. The data were analyzed using Student's t test and the chi-square test or Fisher's exact test, as appropriate. Statistical significance was set at P < .05. A descriptive cost analysis was also performed and compared with those from previously published studies. RESULTS: The data from 86 subjects were included in the present study. Of the 86 subjects, 33 were in the embrasure wire group and 53 in the arch bar group. Of the patients in the arch bar group, 26% had complications compared with 15% in the embrasure wire IMF group. No statistically significant difference between the groups in terms of infection (P = .63), hardware failure (P = .75), malocclusion (P = .85), and nonunion (P = 1.0). However, the cost of arch bar placement and removal was approximately $2,672 more than the placement of embrasure wires. CONCLUSIONS: Patients treated with embrasure wire IMF had slightly better clinical outcomes compared with those treated with arch bar IMF. Also, the cost reduction for patients treated with embrasure wire IMF was significant.

Outcomes of mandible fracture treatment at an academic tertiary hospital: a 5-year analysis.

PURPOSE: To analyze the outcomes of mandible fractures treated using open reduction and internal fixation. PATIENTS AND METHODS: We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded. RESULTS: Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495). CONCLUSIONS: A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.

Does ketorolac have a preemptive analgesic effect? A randomized, double-blind, control study.

PURPOSE: To examine the effect of ketorolac used as preemptive analgesia on the intensity of pain and analgesic requirements in the postoperative period. PATIENTS AND METHODS: The present study was a randomized, double-blind, control study involving human subjects who underwent extraction of the mandibular third molars under intravenous anesthesia. The study group received 30 mg of intravenous ketorolac preoperatively, and the control group received a placebo. The pain intensity was measured using a visual analog scale. The decrease in postoperative pain was measured as the primary outcome variable. The interval to the first dose of analgesic, total analgesic requirements, and the global assessment were measured as secondary outcomes. The data were analyzed using the Student t test, Wilcoxon rank sum test, and χ(2) test. RESULTS: A total of 85 adult subjects, American Society of Anesthesiologists class I and II, participated in the present study. Randomization was effective, as shown by the absence of differences in the study variables between the 2 groups. Of the 85 patients, 29 were men and 56 were women. The average patient age was 22.6 years in the study group and 24 years in the control group. Those in the ketorolac group recorded lower visual analog scale pain scores at all intervals. However, the difference was statistically significant at the 4-hour interval (P = .01). The median interval to the use of rescue medication in the ketorolac group was 9.5 hours compared with 7 hours in the control group. However, no statistically significant difference was found in the interval to the rescue analgesic between the 2 groups (P = .39). No statistically significant difference was noted in the total amount of postoperative analgesics required in the first 72 hours between the 2 groups (P = .54). Also, no difference was seen in the global assessment between the 2 groups (P = .22). CONCLUSIONS: Those who received 30 mg of intravenous ketorolac preoperatively had less pain in the early (8-hour) postoperative period. The median interval to rescue medication was 2 hours longer in the ketorolac group. However, the difference in the total narcotic consumption was clinically and statistically insignificant between the ketorolac and control groups.

Orbital, periorbital, and ocular reconstruction.

The repair and restoration of the eyelids and orbit can be a medical and surgical challenge. Inadequate orbital volume restoration could lead to poor functional and cosmetic defects. With advances in technology, our surgical techniques are constantly improving. This article focuses on ocular and orbital reconstruction following traumatic, iatrogenic, and acquired defects. Optimal outcomes can only be expected with appropriate diagnosis treatment planning in consultation with other specialists.

Characteristics and cost impact of severe odontogenic infections.

OBJECTIVE: The objective of this study was to retrospectively analyze the clinical presentation, surgical management, and cost implications of inpatients treated for odontogenic infections at a public tertiary care hospital. STUDY DESIGN: Specific analysis from 3 years of chart review included length of stay, cost of hospitalization, site of infection, number of infected spaces, microbiology profile, antibiotics administered, intensive care unit (ICU) stay, number of days intubated, comorbidities, number of operating room visits, imaging studies, and whether the patients received preadmission treatment. RESULTS: Multiple fascial spaces were involved in most of the infections. The average length of stay was 4.57 days and average time in the ICU was 3.1 days. Ninety percent of the patients had a coexisting medical comorbidity. The overall hospital costs totaled $749,382 averaging $17,842 per person. CONCLUSIONS: This study reveals a staggering cost burden on a public health care facility as a result of odontogenic infections.

Reoperative temporomandibular joint surgery.

TMJ surgeries are not always successful. Many potential pitfalls can occur during any phase of the treatment and can lead to complications, less than desirable results, and short- or long-term failures. Unsatisfactory results can occur for multiple reasons, including misdiagnosis of the original pathologic condition, incorrect selection of surgical technique, technical failures, complications, systemic disease, and unrealistic expectations. This article focuses on the reoperation of the TMJ primarily in cases of internal derangement and discusses TMJ arthrocentesis, arthroscopy, modified condylotomy, and open joint procedures.

Bone graft harvesting from regional sites.

Bone grafts are widely used in the reconstruction of osseous defects in the oral and maxillofacial region. Successful osseointegration of dental implants requires sufficient bone surrounding the implant. Although bone substitutes and augmentation techniques offer viable prognoses for achieving the required amount of hard tissue augmentation, autologous bone is the gold standard with regard to quantity, quality, and an uneventful healing. Autogenous bone grafts are generally obtained from the ilium, the rib, and the calvarium. Alternative sources for local harvesting in the mandible can be evaluated by careful clinical and radiographic examinations of the patient. This article discusses the various sources of grafts and the techniques used to harvest bone.

Characteristics of head and neck cancer patients referred to an oral and maxillofacial surgeon in the United States for management.

PURPOSE: The purpose of this study was to report the characteristics of patients with head and neck cancer, excluding cutaneous malignancies, referred to an oral and maxillofacial surgeon in the United States for management. MATERIALS AND METHODS: We performed a retrospective chart review of all head and neck cancer patients referred to the senior author's oral and maxillofacial surgery practice over 12 consecutive months. Data were extracted from the patients' comprehensive record and included demographics, social history, site, histologic diagnosis, staging, treatment, and referral patterns. RESULTS: A total of 90 patients, 51 men and 39 women (male-female ratio, 1.3:1), with a mean age of 64.4 years (range, 32-91 years) were referred with head and neck cancer, excluding skin cancer, over the 12-month period and were included in the study. Regarding ethnicity, 88.8% of the patients were white, 11.1% African American, and 1.1% Asian. Most of the patients, 84.4%, were referred from within the state, but only 21.1% of these resided within the metropolitan area of the senior author's practice. Of the patients in the study population, 95.5% had either private or state-provided/federally provided insurance. Social history showed that 59.9% of patients were current or past smokers, 31.1% were nonsmokers, and 8.8% were smokeless tobacco users, and only 18.8% admitted to alcohol use. Approximately 80% of patients were initially evaluated by a general dentist, oral and maxillofacial surgeon, or periodontist, and 93% of referrals were from other oral and maxillofacial surgeons. Over 90% of lesions were located in the oral cavity, and only 6.6% were oropharyngeal primary cancers. Squamous cell carcinoma made up 89% of the lesions, whereas minor salivary gland and metastatic carcinomas comprised the other 11%. At the time of diagnosis, 64.4% of the lesions were early stage (I/II) and 35.6% were late stage (III/IV). Analysis of treatment modalities showed that 87.8% underwent surgery, excluding biopsy, as part of their therapy. Of these, 83.5% were treated with surgery only, whereas the others received both surgery and some form of adjuvant therapy. Five patients were treated with concurrent chemoradiation therapy. CONCLUSION: Our results suggest that patients referred to an oral and maxillofacial surgery practice for management of head and neck cancer are different from those described in previous reports regarding demographics, social history, site, and stage of disease at diagnosis and treatment. This finding may be explained by the unique referral pattern for oral and maxillofacial surgeons treating head and neck cancer.

Barrier membranes used for ridge augmentation: is there an optimal pore size?

PURPOSE: To identify the optimal pore size of barrier membranes for successful alveolar ridge reconstruction procedures, to determine if cortical perforations have any effect on bone regeneration, and to reiterate that bone graft containment is an important parameter for successful regeneration. MATERIALS AND METHODS: This was a prospective, randomized, controlled study performed on hound dogs. Corticocancellous tibial bone grafting was performed to the lateral border of the mandible and protected with barrier membranes (meshes). The experiment analyzed three different pore sized meshes, compared with controls without the mesh. Two meshes (macroporous and microporous) were made of titanium, and one was a resorbable mesh. Meshes were preformed into the shape of a cube with one face open. Each side of the cube measured approximately 10 mm. Cubes were open-faced on one side, to facilitate packing of the graft material. The dogs received bilateral ramus grafts. Cortical perforations were created on the left ramus of all the dogs and compared with the right side, which did not have perforations. The dogs were randomly divided into 3 groups and sacrificed at intervals of 1, 2, and 4 months. Before sacrifice, all dogs received 2 doses of tetracycline as a marker for new bone formation. Histomorphometry was performed by using Bioquant image-analysis software. Areas of new bone and soft tissue were measured. The rate of mineral apposition was also calculated. All values obtained via histomorphometry were statistically analyzed with a t test. RESULTS: Thirty-one experimental sites were evaluated. The amount of new bone growth into the macroporous mesh was significantly higher than in the other groups. The mean area of new bone formation in large and small meshes was 66.26 +/- 13.78 mm(2) and 52.82 +/- 24.75 mm(2), respectively. In the resorbable mesh group, the mean area of new bone formed was 46.76 +/- 21.22 mm(2). The amount of new bone formed in the control group was 29.80 +/- 9.35 mm(2). There was no significant difference in amount of bone formation between left and right sides (P = .3172). Resorbable meshes had significant soft tissue ingrowth (23.47 mm(2)) compared with macroporous mesh (16.96 mm(2)) and microporous mesh (22.29 mm(2)). Controls had the least amount of soft tissue ingrowth (9.41 mm(2)). Mineral apposition rate was found to be higher in the resorbable group (2.41 microm/day), and the rate was lowest (1.09 microm/day) in the large pore mesh group. CONCLUSION: Macroporous membranes facilitated greater bone regeneration compared with microporous and resorbable membranes. Macroporous mesh also prevented significant soft tissue ingrowth compared with other meshes. Containment of a bone graft is the most critical parameter in successful bone regeneration. Cortical perforations did not have any effect on the quantity of regenerated bone. Further research should be directed toward identifying a critical pore size and manufacturing a reliable mesh that would prevent excessive soft tissue ingrowth in ridge augmentation procedures.

Outcomes of calvarial bone grafting for alveolar ridge reconstruction.

PURPOSE: This article describes a series of patients who underwent calvarial bone grafting (CBG) for reconstruction of extremely edentulous jaws for the purpose of implant placement. MATERIALS AND METHODS: A retrospective review was conducted of all patients treated with split CBGs to the atrophic maxilla or mandible between 1999 and 2006. All patients were monitored for signs of infection, dehiscence, or other complications. The amount of augmentation was measured on panoramic radiographs. RESULTS: A total of 15 reconstructed sites (eight maxillary, seven mandibular) in 13 consecutive patients with a mean preoperative height of 6 mm (range, 3 to 9 mm) were included in the study and followed for a mean of 32 months. Ten women and three men aged 40 to 88 years (mean, 63 years) underwent surgery. There were no complications associated with the bone harvesting technique, and all implants had primary stability at the time of placement. Two patients had graft exposure in the maxilla. Two implants were removed in one patient. On average, the gain in ridge height was 15 mm (range, 10 to 19 mm). A total of 53 implants were placed, with an average of four implants per patient. CONCLUSION: Split CBGs to the atrophic maxilla and mandible can restore optimal height to support and facilitate implant-based restorations. A prospective study with a longer follow-up period is required to evaluate the rate of resorption associated with split CBG. Immediate placement of implants at the time of grafting in the mandible shortens the treatment time.

Sjögren syndrome: a review for the maxillofacial surgeon.

Sjögren syndrome is a multisystemic condition that predominantly involves the salivary and lacrimal glands. Also known as sicca complex, the disease often is underdiagnosed and poorly understood. This article provides a comprehensive review on Sjögren syndrome, with an emphasis on diagnosis and treatment modalities.

Head and neck manifestations of distant carcinomas.

Metastatic tumors to the head and neck from distant carcinomas are rare lesions that epitomize the "zebras." They represent a diagnostic and therapeutic challenge for clinicians and health providers. These lesions usually rank low in the differential diagnosis list, but a history of cancer should prompt clinicians about the possibility of a metastatic lesion from a distant carcinoma. The presence of these lesions usually represents a poor prognosis. The surgeon's role in treating these lesions is to improve or maintain the patient's quality of life, taking into consideration the overall prognosis.

Cystinosis, Fanconi syndrome, and odontogenic cysts.

Cystinosis is a multisystemic genetic storage disorder characterized by a mutation in the transporter system of cystine. The disease particularly affects the renal system by causing deposition of cystine crystals leading to, if untreated, Fanconi syndrome and end-stage renal disease. This disease also affects the ocular system, central nervous system, endocrine system, hepatobiliary system, and musculoskeletal system. We present the first case of cystine crystal deposition within an odontogenic cyst, confirmed by the correlation of the clinical, radiographic, and histologic findings on this patient.

Cranial bone grafting and simultaneous implants: a submental technique to reconstruct the atrophic mandible.

Results after treatment of severe maxillary and mandibular atrophy (Cawood classes V and VI) are often unsatisfactory and unpredictable. Reconstruction of such severely resorbed edentulous jaws represents a challenge. In maxillofacial surgery, bone grafts from the skull (split calvarial bone grafts) are commonly used for reconstruction of large bone defects of the midface. In the 1990s, various authors reported alveolar-ridge augmentation using calvarial bone grafts. This is the first report of its kind describing an extraoral approach for cranial bone grafting with simultaneous implant placement to the atrophic mandible.

Reconstruction of the maxilla and mandible with particulate bone graft and titanium mesh for implant placement.

PURPOSE: The purpose of the study was to evaluate the magnitude of ridge augmentation with titanium mesh, overall graft success, anatomic location of ridge defects and their relationship to mesh exposure. MATERIALS AND METHODS: This retrospective study evaluated 44 patients who received mandibular or maxillary reconstruction with autogenous particulate bone graft and titanium mesh for the purpose of implant placement. Autogenous bone graft was harvested from the iliac crest, tibia, and mandibular symphysis. A total of 45 sites were included in the study. Average augmentation bone heights were measured and compared. Statistical analysis was done with ANOVA and Student's t test. Histomorphometric analysis was performed on the soft tissue specimen found between the mesh and the bone graft. RESULTS: Twenty-nine sites underwent mandibular reconstruction and 16 underwent maxillary reconstruction. The mean augmentation in partial maxillary defects was 11.33 +/- 1.56 mm, and in complete maxillary augmentation, the height achieved was 14.3 +/- 1.39 mm. In the mandible, mean increase in height for partial defects was 14 +/- 1.42 mm and for complete augmentation it was 13.71 +/- 1.14 mm. The mean augmentation for all sites was 13.7 mm (12.8 mm in the maxilla and 13.9 mm in the mandible). A total of 82 implants were placed in the maxilla and 92 implants were placed in the mandible. In the maxillary group, 7 sites had exposure of the titanium mesh and 16 sites were exposed in the mandible. The success of the bone grafting procedure was 97.72%. CONCLUSIONS: Porous titanium mesh is a reliable containment system used for reconstruction of the maxilla and the mandible. This material tolerates exposure very well and gives predictable results.

Bisphosphonates and osteonecrosis of the jaws: science and rationale.

Bisphosphonates as a group of drugs were introduced for the management of various conditions such as osteoporosis, Paget's disease, multiple myeloma, hypercalcemia of malignancy, breast cancer, prostate cancer, and other tumors. This group of drugs has improved the quality of life in many patients with proven efficacy in limiting pain and skeletal-related events. The controversy of osteonecrosis of the jaws and bisphosphonates is a recent and growing problem. Osteonecrosis of the jaws is recognized as a serious complication of bisphosphonate therapy, more commonly with the intravenous form of the drugs. However, there is limited scientific understanding about the association between osteonecrosis of the jaws and bisphosphonates. In the present article we discuss various mechanisms of action of bisphosphonates, the rationale for occurrence of osteonecrosis in the jaws, and treatment guidelines for the condition.

Intraoperative imaging techniques: a guide to retrieval of foreign bodies.

Foreign bodies are frequently introduced into the tissues of the head and neck by various mechanisms, and oral and maxillofacial surgeons are often called upon to retrieve these embedded objects. Retrieval may be quite challenging depending on many factors such as the size of the object, the location, and the surrounding anatomical structures. Preoperative imaging is very important in deciding upon the surgical approach. Computerized tomography is considered the gold standard for detection of foreign bodies because of the ability to localize an object in multiple planes and the creation of a 3-dimensional image. Difficulty arises when looking for a small object in an area with multiple important anatomical structures, such as the infratemporal fossa or the neck. Surgery can become tedious secondary to the risk of postoperative morbidity with injury to various anatomical structures. Foreign bodies in the head and neck are often difficult to manage even when a plan has been formulated from static preoperative images. Intraoperative feedback or guidance, especially when navigating through troublesome locations, can be extremely useful. In this paper, we report 2 cases and discuss the various modalities used for intraoperative imaging as a guide for surgical retrieval of foreign bodies.