Self-drilling screws for the prevention of dental and skeletal injuries during open reduction and internal fixation of pediatric mandibular fractures.

Facial trauma in pediatric population predisposes the child to injury of both the developing skeleton and dentition. This article aims to highlight the experience of the authors through a case report, in using self-drilling screws for fixation of mandibular fractures in pediatric age group. The use of self-drilling screws minimizes the complications such as thermal and/or mechanical damage to the developing dentition and the bone. They also provide significant advantages including ease of availability and technique, superior anchorage with primary stability, and minimizing or avoiding permanent damage to the developing tooth germs in the site of fracture. The use of self-drilling screws for mandibular open reduction and internal fixation in children is an easy, reliable, and safe technique which may have significant value addition in preventing inadvertent injury to the developing tooth germs.

Odontoma complejo: resolución de un caso con utilización de osteosíntesis rígida por riesgo de fractura mandibular / Complex odontoma: case resolution with the use of rigid osteosynthesis for risk of mandibular fracture

Objetivo: Describir la resolución de un caso un odontoma complejo de gran tamaño con utilización de osteosíntesis rígida. Caso clínico: Una paciente de 13 años de edad se presentó a la consulta por aumento de volumen en hemifacia izquierda, de 4 meses de evolución. Mediante biopsia incisional, se diagnosticó odontoma complejo. Se realizó tratamiento quirúrgico con utilización de osteosíntesis rígida. Se decidió retirar la placa de osteosíntesis a los 6 meses posoperatorios para evitar alterar el crecimiento y el desarrollo mandibular. Se indicó control posoperatorio durante 5 años. Conclusión: La utilización de osteosíntesis rígida fue adecuada para reforzar el defecto óseo mandibular producido durante el tratamiento quirúrgico de un odontoma complejo de gran tamaño (AU)

Aim: To describe the resolution of a case of a large complex odontoma with the use of rigid osteosynthesis. Clinical case: A 13-year-old patient presented with a swelling in left jaw of 4 months of evolution. Complex odontoma was diagnosed by incisional biopsy. Surgical treatment was performed with the use of rigid osteosynthesis. Removal of osteosynthesis plate was decided 6 months postoperatively to avoid alteration of mandibular growth and development. Postoperative control was indicated for 5 years. Conclusion: The use of rigid osteosynthesis was adequate to reinforce the mandibular bone defect produced during the surgical treatment of large complex odontoma (AU)

Removal of a severely impacted mandibular third molar minimizing the risks of compromised periodontium, nerve injury, and mandibular fracture.

A technique is presented for severely impacted and dentigerous-cyst-related mandibular third molar removal, avoiding any associated risks. CASE PRESENTATION: A healthy patient complained about unpleasant smell and taste in the mouth and unilateral extraoral palpation of a protuberance, at the right corner of the mandible. Restricted field CBCT showed a severely impacted third molar, which penetrated the inferior cortical bone of the mandibular corner and was associated with a dentigerous cyst that had resorbed considerable bone in the region. Surgical exposure of the impacted tooth and cyst marsupialization procedures under local anesthesia were combined with orthodontic extrusion of the impacted tooth to facilitate third molar removal. Treatment resulted in successful bone formation and safe tooth removal. The symptoms gradually improved after the first surgery and were eliminated by 14 months later, when the third molar was removed. Follow-up examination 1 year after removal showed favorable periodontal conditions. CONCLUSION: Although it is not normally the first treatment of choice, orthodontically assisted impacted tooth removal is an alternative that can minimize the risk of compromised periodontium or injury to the adjacent tooth and the inferior alveolar nerve, as well as the risk of mandibular fracture, in complicated cases.

Prevention of bisphosphonate-related mandibular fractures.

Mandibular fracture is usually the clinical end of bisphosphonate-related osteonecrosis of the jaw. This is a painful complication and patients cannot feed as usual, with a worsening of their quality of life. The goal of treatment in bisphosphonate related osteonecrosis of jaw (BRONJ) patients is to slow progression of bone necrosis. We present a novel technique for treatment of severe mandibular BRONJ in stage 3 patients that present with a high risk to develop fracture, since they have a residual unaffected mandibular bone height less than 6 mm. We treated 10 patients in this clinical situation with an extra-oral application of a reconstructive plate superficial to the platysma, to keep the plate separated from the infected site to avoid contamination and consequent need of removal, followed by an intraoral approach for active curettage of mandibular necrosis. The preservation of blood supply to the mandible and avoidance of direct contact of the infected site with the reconstructive plate are some advantages of this technique. This plate allows enhancement of mandibular strength, allowing proper treatment of the BRONJ site on the oral side without fear of causing a mandibular fracture when the residual mandible is thin. This technical solution guarantees these patients an extended disease-free period since it is effective in preventing mandibular fractures in patients with low mandibular residual height left after the BRONJ onset.

Identifying the risk factors causing iatrogenic mandibular fractures associated with exodontia: a systemic meta-analysis of 200 cases from 1953 to 2015.

PURPOSE: Iatrogenic fracture of mandible (IFM) associated with exodontia though rare, they do occur with an incidence ranging from 0.0034 to 0.0075 %. Most of the data is in the form of case reports or a small case series. This is an attempt to amass the data available in literature since the last 62 years. The purpose of this meta-analysis is to identify the etiologies and risk factors leading to IFM associated with exodontia and also the measures to minimize the complication. METHODS: Articles published between 1953 and 2015 were searched in Medline database. Data was collected and analyzed based on age, gender, extracted tooth, status of dentition, pathological bone lesion adjacent to the tooth, type of impaction, angulation of the impacted third molar, site of fracture, side of fracture, time of fracture, and treatment of fracture. RESULTS: A review identified 200 documented cases of IFM associated with the removal of teeth. The reasons for its occurrence found to be multifactorial with a higher incidence in the fifth decade of life with male prevalence. Risk factors more commonly identified were removal of the third molar, fully dentate patient, associated pathology, impacted tooth, angle region, left quadrant, and time interval of 3 weeks postoperatively. CONCLUSIONS: IFM related to the removal of teeth is a rare complication. Identifying and addressing the risk factors will enable the surgeon to avoid the complication of IFM associated with exodontia.

Perfil epidemiológico dos pacientes portadores de fraturas de face / Epidemiological profile of patients with facial fractures

Fraturas faciais foram provocadas principalmente por acidentes de trânsito (37,3%), e por agressões físicas (33%), vitimando predominantemente pacientes do gênero masculino (83,7%).Ocorreram mais frequentemente na faixa etária entre 21 e 30 anos (38,2%). A frequência de homens e mulheres vitimados entre a primeira e a terceira décadas de vida foi bastante similar.As fraturas mandibulares isoladas foram significativamente predominantes (48%), seguidas pelas zigomáticas (19,7%) e pelas nasais (19,7%). As agressões físicas foram mais frequente mente responsáveis pelas fraturas mandibulares, zigomáticas, nasais, maxilares e frontais, enquanto as fraturas pan faciais e Le Fort resultaram mais frequentemente de acidentes de trânsito.

Facial fractures were mainly caused by traffic accidents (37.3%) and physical abuse (33%), victimizing mostly male patients (83.7%). Occurred more frequently in the age group between21 and 30 years (38.2%). The frequency of men and women victimized between the first and third decades of life was very similar. Isolated mandibular fractures were significantly predominant(48%), followed by zygomatic (19.7%) and the nose (19.7%). The assaults were mostoften responsible for mandibular fractures, zygomatic, nasal, maxillary and frontal, while the panfaciais fractures and Le Fort resulted more often aciteeth transit.

Clinical study on mandibular fracture after marginal resection of the mandible.

OBJECTIVES: Postoperative mandibular fracture (PMF) after marginal resection (MR) of the mandible remains an unresolved issue, and it has been reported that at least 10 mm of postoperative mandibular body height (PMBH) is required to prevent PMF. This study evaluated the clinical, physical, and structural risk factors for PMF in MR patients and determined appropriate preventive measures for PMF. STUDY DESIGN: This retrospective study included 44 patients with lower gingival carcinoma who underwent MR. PMF occurred in four of these patients. Thirteen associated factors identified from medical records and radiographs were statistically analyzed. RESULTS: Mandibular body height (MBH) preservation ratio originally evaluated as less than 0.3, more than 20 remaining teeth after surgery, and inferior alveolar canal (IAC) exposure were significant risk factors for PMF. Prostheses and number of remaining teeth were also correlated with PMF. CONCLUSIONS: The preserved mandibular bone should be reinforced in patients with an MBH preservation ratio of less than 0.3, more than 20 remaining teeth after surgery, and intraoperative IAC exposure. Patients with prostheses are at an increased risk of PMF compared with those without because of stable occlusion and a strong occlusal force. Our novel findings provide useful reference standards for PMF prevention in MR patients.

Concomitant Third Molar Removal During Sagittal Split Osteotomy of the Mandible.

It is described in textbook about management of third molar in orthognathic surgery that "ideally, the third molars should be removed 9 to 12 months before sagittal split osteotomy (SSO)." At the Chang Gung Craniofacial Center, the authors always remove mandibular third molars during SSO, because: removal of third molars at the same time of SSO could reduce psychological stress on patients by saving 1 surgical procedure under local anesthesia, better exposure of impacted third molars could be facilitated by sagittal split of buccal cortical plate, rigid fixation could be performed without difficulty by our fixation method using plates and screws crossover anterior oblique line. Strong force during the elevation of third molars, however, may result in the fracture of distal segment of SSO, where the buccal cortical plate is relatively thin because of the presence of third molar. Therefore, more care needs to be taken in the surgical technique, which is different from ordinary tooth extraction. In this paper, the details of surgical procedure of third molar removal during SSO were reported.

Epidemiología de las fracturas mandibulares tratadas quirúrgicamente en el Instituto Traumatológico de Santiago (Chile): 10 años de revisión / Epidemiology of surgically treated jaw fractures in the Traumatology Institute of Santiago (Chile): a 10-year review

Los traumatismos en Chile son la tercera causa de muerte en la población general y la primera entre jóvenes. Se ha reportado una epidemiología variable alrededor del mundo asociada a diferencias demográficas y socioculturales, con escasos estudios en Latinoamérica. Objetivo. Conocer la epidemiología de las fracturas mandibulares en el Instituto Traumatológico de Santiago, Chile. Material y método. Estudio retrospectivo descriptivo de tipo cuantitativo en el Servicio de Cirugía Maxilofacial del IT, consistente en la recolección de datos mediante revisión de fichas clínicas de pacientes operados por fracturas mandibulares entre enero de 2001 y diciembre de 2010. Los datos fueron recopilados utilizando una base de datos Microsoft Access 2007 y luego tabulados y graficados con Microsoft Excel 2007. Resultados. De un universo de 783 fracturas faciales, 240 fichas de fracturas mandibulares operadas estuvieron disponibles para su análisis. La proporción hombres:mujeres fue de 5,9:1 y el grupo etario más afectado fue aquel entre 20 y 29 años. Las agresiones por terceros fueron su causa más frecuente. La mayoría de los pacientes fueron tratados en un promedio de 8,6 días desde su ingreso. En conclusión, estos resultados en general son concordantes con la literatura, salvo asociaciones entre sitio anatómico afectado y etiología (AU)

The traumatic injuries in Chile are the third cause of death in the general population and the first in young people. Their epidemiology varies around the world, and is linked to demographic and sociocultural differences, with few studies in Latin America. Objective. To determine epidemiological profile of the jaw bone fractures in the Traumatology Institute (IT) of Santiago, Chile. Material and method. Retrospective descriptive and quantitative study was conducted in the Maxillofacial Surgery Department of the IT, developed by recording data from a review of clinical records of patients with surgicaly treated jaw fractures. Data were collected between January-2001 and December-2010 using Microsoft Access 2007© and then tabulated and plotted using Microsoft Excel 2007©. Results. Out of a total of 783 facial fractures, 240 clinical files of surgically treated jaw fractures were available for analysis. The male:female ratio was 5.9:1, and the most afected age group was between 20 and 29 years old. The most frequent cause of the fracture was aggressions. Most patients were treated in an average of 8.6 days from admission. In conclusion, these results are consistent with the literature, except for the associations between the affected anatomical site and etiology (AU)

Theoretical efficacy of preventive measures for pathologic fracture after surgical removal of mandibular lesions based on a three-dimensional finite element analysis.

PURPOSE: Pathologic fracture of the mandible after removal of a lesion historically has been a clinical problem. The present study aimed to evaluate mandibular strength after removal of a lesion and to illustrate the theoretical efficacy of preventive measures against pathologic fracture based on a 3-dimensional finite element (FE) analysis. MATERIALS AND METHODS: A computed tomographic (CT)-based FE model of the mandible of a patient with a dentigerous cyst including a third molar was constructed. Using this model, the decrease of mandibular strength after virtual removal of the lesion was analyzed. The effect of the decrease of occlusal force and reinforcement by a miniplate was analyzed using a simple FE model of the mandible. Based on these analyses, removal of the cyst with the third molar was performed with a decrease of occlusal force and reinforcement by a miniplate. The validity of these procedures was analyzed using a CT-based FE model constructed after surgery. RESULTS: The von Mises stress in a CT-based FE model after virtual removal of the cyst with the third molar was markedly greater than that in the original FE model. In the analysis using a simple FE model, the stress around the fenestrated area was decreased after premolar loading compared with that after molar loading. In addition, miniplate placement around the fenestrated area markedly decreased the stress. Based on these results, the cast crowns of the first and second molars were removed and the fenestrated area of the mandible was reinforced with a 1.5-mm locking miniplate in the actual surgery. The von Mises stress in the fenestrated area was decreased and primarily borne by the miniplate in the analysis of a CT-based FE model constructed after surgery. CONCLUSION: The present study illustrated the theoretical efficacy of plate application for the decrease of stress on the mandible after surgical removal of a cyst including a third molar based on a simulation by FE analysis.

[Complex treatment of mandibular malignant tumors using a fixing device for prophylaxis of pathological fracture, the early postoperative prosthesis and rehabilitation].

Even in modern conditions of achievements in the head and neck oncosurgery the restoration of the volume defects of the bone tissue in a jaw-facial region is impossible to do without the orthopedic methods application because of present severe psychoemotional and general state of the patients. The problem of prophylaxis of mandibular pathological fractures in its malignant affection constitute a peculiar place, taking into account a complexity and numerousness of the unsolved issues. There was elaborated and constructed apparatus for the pathological fracture prophylaxis or for fixing of fragments in the angle of a toothless mandibula. After the apparatus being applied in place the patient's quality of life improves: they better tolerate radiation therapy; the conditions for surgical treatment are improving; the acts of chewing and deglutition are not disordered, what improves the patients state significantly; the general image of the face is not disturbed. The methods may be introduced into specialized clinics.

Short-term effect of zoledronic acid upon fracture resistance of the mandibular condyle and femoral head in an animal model.

OBJECTIVE: The aim of this study was to compare the effects in terms of resistance to fracture of the mandibular condyle and femoral head following different doses of zoledronic acid in an animal model. STUDY DESIGN: A total of 80 adult male Sprague-Dawley rats were included in a prospective randomized study. The animals were randomly divided into four groups of 20 rats each. Group 1 (control) received sterile saline solution, while groups 2, 3 and 4 received a accumulated dose of 0.2 mg, 0.4 mg and 0.6 mg of zoledronic acid, respectively. The animals were sacrificed 28 days after the last dose, and the right hemimandible and the right femur were removed. The fracture strength was measured (in Newtons) with a universal test machine using a 1 kN load connected to a metal rod with one end angled at 30 degrees. The cross-head speed was 1 mm/min. Later, the specimens were observed under a scanning electron microscope with backscattered electron imaging (SEM-BSE). At last, chemical analysis and elemental mapping of the mineral bone composition were generated using a microanalytical system based on energy-dispersive and X-ray spectrometry (EDX). RESULTS: A total of 160 fracture tests were performed. The fracture resistance increased in mandible and femur with a higher accumulated dose of zoledronic acid. Statistically significant differences were recorded versus the controls with all the studies groups. The chemical analysis in mandible showed a significantly increased of calcium and phosphorous to compare the control with all of the study groups; however, in femur no statistically significant differences between the four study groups were observed. CONCLUSIONS: The administration of bisphosphonates increases the fracture resistance in mandible and femur.

The comparison of angular and curvilinear marginal mandibulectomy on force distribution with three dimensional finite element analysis.

AIM: The purpose of this study was to analyse and compare right angled and curved osteotomy design on stress distribution and to determine an osteotomy design which decreases the risk of pathologic fracture. PATIENTS AND METHODS: Solid mathematical model of the mandible was created by three dimensional finite element analysis and two different osteotomy, right angled and curvilinear osteotomy was performed on model. 150 N incisal force vertically and 250 N molar force to the angulus area oblically were applied. The effects of osteotomy types to the stress formation and risk of fracture between models were evaluated. RESULTS: Right angled osteotomy causes much more stress in the posteroinferior quadrant and mainly localized on the horizontal and vertical osteotomy intersection area. On the other hand, the distribution of the stress on curvilinear formed osteotomy shows posteroinferior localization and stress spreads wider area. Furthermore the amount of stress was less than right-angled one. CONCLUSION: In this study, curved osteotomy denominated less stress distribution. The shape of osteotomy might be a factor to decrease the risk of postoperative atrophic mandible fracture.

Enlargement of a Stafne cyst as an indication for surgical treatment - a case report.

Stafne cysts are often defined as static lesions located in the angle of the mandible. Consequently many authors have proposed that there is no need for surgical treatment of these bony defects on the lingual side of the mandible. This article describes the case of a 55-year-old patient, in whom a Stafne cyst showed a significant enlargement, reaching a size that necessitated surgical intervention because of the risk of pathological fracture. A literature search showed 5 additional similar cases, where progression in the size of a Stafne cyst could be radiographically documented. Consequently, the recommended management of these pseudocysts should be reconsidered.

Risk factors and prevention of bad splits during sagittal split osteotomy.

PURPOSE: One of the operative complications of the sagittal split osteotomy of the mandible is a bad split, which describes an unfavorable or irregular fracture of the mandible in the course of the osteotomy. The purpose of this study is to identify previous studies which reported incidences of bad split occurrence during sagittal split osteotomy and to discuss its mechanisms and risk factors, based on a literature review, in order to minimize their occurrence. A few illustrative cases are also presented. METHODS: An electronic search was undertaken in January 2011. The titles and abstracts from these results (n = 363) were read for identifying studies which reported incidences of bad split occurrence during sagittal split osteotomy procedures. RESULTS: Twenty-one studies were identified and assessed. The incidence of bad splits from these studies varied between 0.21% and 22.72%. The buccal plate of the proximal segment and the posterior aspect of the distal segment were the most affected areas. DISCUSSION: The surgical patient should be evaluated according to age and the presence of unerupted/impacted third molars. Prevention is focused on adequate osteotomy design, eliminating sharp angle where abnormal stress occurs on bony segments, completion of adequate cuts into the retrolingular depression and through the inferior border, and careful separation of the segments. The SSO is an extremely technical and sensitive procedure, and careful attention will probably prevent most unfavorable splits. If a fracture occurs, the fractured segments should be incorporated into the fixation scheme if possible. The occurrence of bad splits cannot always be avoided. When adequately treated the chances of functional success are good.

Two-stage surgical removal of large complex odontoma.

PURPOSE: The surgical treatment of a large complex odontoma in the mandibular angle is reported. Four possible surgical approaches to remove a benign tumor in the mandibular angle are discussed. PATIENT: A two-stage surgical treatment was chosen; first, removing most part of the lesion and preserving the second molar, decreasing the risk of a pathological mandibular fracture. A maxillo-mandibular fixation for a period of 4 weeks was used. The patient was oriented to maintain a soft diet. The second surgical stage occurred 3 months after the first one due to the significant bone consolidation observed, reducing the possibility of a mandibular fracture. The remaining lesion and the second molar were then completely removed. CONCLUSIONS: This case demonstrates the value of the tridimensional computed tomography in treatment planning prior to any definitive surgery. A computed tomography should be made in every case of intraosseous lesion in order to establish the intraosseous extent of the tumor, cortical perforation, and soft tissue involvement for precise guidance for the surgical planning. It is recommended that the surgeon considers excision by an intraoral, lingual approach when indicated, and in two stages, when an extremely thin mandibular base is present.