A protocol for the management of compound mandibular fractures based on the time from injury to treatment.

PURPOSE: The purpose of this study was to evaluate the validity of a treatment protocol for compound mandibular fractures that is based on the time of injury to treatment. PATIENTS AND METHODS: Fifty-two patients with 71 mandibular fractures were treated in a prospective fashion in conformity with the protocol. Thirty-seven open reductions with rigid fixation were performed on 30 patients. The remaining 22 patients were treated solely with closed reduction and maxillomandibular fixation (MMF). Forty-five patients were treated before 72 hours and 7 after 72 hours. RESULTS: Fifty-one of the 52 patients healed without evidence of infection. One patient developed suppurative osteomyelitis. Thus, the bone infection rate was 1.9% for all patients treated and 3.3% for patients treated with rigid fixation (ORIF). CONCLUSION: These results underscore the validity of the treatment protocol to immobilize compound fractures within 72 hours of injury, if possible. If the initial treatment is delayed for more than 3 days, any infection at the compound fracture site(s) should first be resolved by MMF and intravenous antibiotics before performing an open reduction. This is done to ensure adequate perfusion of blood at the fracture site when the open reduction is performed.

Early immobilization of mandibular fractures: a retrospective study.

This study reviews the treatment outcome of 204 fractures in 131 patients over a 33-month period. In the total group, an infection rate of 4.4% was experienced, which is comparable with other reports. However, in complaint patients immobilized within 72 hours of injury, there was a 0% incidence of bone infection in 111 fractures treated by closed reduction and a 2% (one case) incidence of bone infection in 50 fractures treated by open reduction. Thus, of the of 161 fractures treated by closed and/or open reduction with early immobilization in complaint patients, the incidence of posttreatment bone infection was 0.6%. It was not significant whether teeth in the line of fracture were retained or removed. This study supports the principle that compound fractures of the mandible should to be immobilized within 72 hours of the initial trauma.

Augmentation of the atrophic edentulous maxilla with hydroxylapatite.

A technique for augmentation of the severely atrophic edentulous maxilla is presented. This technique combines the mobilization of the available soft tissue of the labial vestibule with a subperiosteal reflection and "filleting" of the redundant crestal soft tissue to create ample space to accommodate the insertion of the desired amount of hydroxylapatite. The surgical development of a distinct labial periosteal flap by both a subperiosteal and supraperiosteal dissection allows a two-layered lapped closure of the mucosal and periosteal flaps. Fourteen patients were treated with this technique and have been observed for period of 8 to 40 months. Arch form was dramatically improved in all cases. Observation of panoramic radiographs disclosed an average initial increase in ridge height of 11.8 mm in the midline and 7.6 mm in the first premolar regions. During the first 6 months, consolidation of the ridge occurred, but the diminution in ridge height never exceeded 15%.

Bilateral maxillary squamous odontogenic tumors and the malignant transformation of a mandibular radiolucent lesion.

A case of bilateral squamous odontogenic tumors of the maxilla with concomitant malignant transformation of a mandibular lesion to squamous cell carcinoma is presented. It is the first reported case of squamous odontogenic tumor in coexistence with a malignant tumor.

Fetal alcohol syndrome.

A case of fetal alcohol syndrome in an 8-month-old infant is presented. Several of the maxillofacial anomalies associated with this syndrome were present. In addition, a large dentigerous cyst was found, a rare lesion occurring with a deciduous tooth and never before reported in association with fetal alcohol syndrome.

Denture stabilization with peralveolar tubing.

Mock dentures were stabilized in six monkeys by means of polyethylene tubings passed through surgically created buccolingual peralveolar channels. Macroscopic, radiographic, and microscopic examinations demonstrated that the dentures were stabilized and the tubings well tolerated throughout the 120-day study period.

Carotid-cavernous sinus fistula after trauma to the head.

The similarities between the various conditions described are remarkable. The orbital or frontal bruit and pulsating exophthalmos are common only to the carotid-cavernous fistula. A recent history of dental treatment, of facial infection with an elevated white blood cell count, and leukocytosis suggests cavernous sinus thrombosis. The superior orbital fissure syndrome and orbital apex syndrome occur most frequently in conjuction with Le Fort II and III fractures, which can involve the optic foramen and superior orbital fissure, therefore disrupting the sensory and motor innervation to the orbit and adjacent structures (Fig 4). Direct orbital trauma without evidence of fracture and with all symptoms mentioned, except infection, bruit, and pulsating exophthalmos, suggests orbital hematoma. A thorough differential diagnosis with complete data is essential for a correct diagnosis, thereby reducing morbidity by institution of the appropriate treatment. Treatments for carotid cavernous fistula have varied over the years--all aiming toward abolition of the fistula. Currently, the preferred treatment is the supraclinoid clamping of the internal carotid artery, followed by muscle embolization of the internal carotid artery distal to the bifurcation, and clamping of the internal carotid artery in the neck.

Immediate vestibuloplasty with fenestrated and intact full-thickness mucosal grafts.

Intact and fenestrated full-thickness palatal mucosal grafts were placed following immediate vestibuloplasty in ten dogs of mixed breed. Macrscopic and microscopic findings indicated that the fenestrated grafts were as effective as the intact grafts in long-term maintenance of bestibular depth.

Local injection of corticosteroids with vestibuloplasty.

Triamcinolone acetonide was injected into the mucobuccal fold adjacent to the surgical site where a vestibuloplasty with mucosal grafting had been performed. Macroscopically, the mucobuccal folds of the experimental group were both softer than those of the control animals and exhibited less tendency toward regression in the depth of the vestibule. Microscopic examination revealed qualitative rather than quantitative changes in collagen formation.

Multiple facial trauma complicated by occlusion of the internal carotid artery.

The occurrence of thrombosis of the internal carotid artery is a rare entity. Such a case, in association with multiple facial fractures, has been presented. The management of the patient was complicated by neurological disturbances that affected definitive treatment. This case illustrates the importance of close monitoring of all patients with facial trauma before, during, and after surgery.

Squamous-cell carcinoma of the floor of the mouth with extensive mandibular involvement.

The case of a patient with an extensive squamous-cell carcinoma of the floor of the mouth with erosion of the mandibular bone is presented. The history and initial clinical picture were consistent with either carcinoma with superimposed infection or chronic osteomyelitis with an acute exacerbation. A discussion of diagnosis and treatment of carcinoma of the floor of the mouth follows this case report.

Fenestrated palatal mucosal grafts for vestibuloplasty.

Vestibuloplasties with fenestrated palatal mucosal grafts were successful in eight patients. The fenestrated palatal mucosa provides a tough, full-thickness, resilient mucosal graft from a limited donor site. The operating time is decreased, bleeding is minimized, and healing time of the donor site is shortened. Fenestration allows seepage of blood and tissue fluids from beneath the graft. The fenestrated grafts are readily adaptable to any irregularities of the edentulous mandibular ridge.

Mandibular actinomycosis: report of case.

A case of mandibular actinomycosis, secondary to a compound fracture in an alcoholic patient, is described. The factors that apparently enhance the development of this disease are discussed.