Nonunion of the mandible: an analysis of contributing factors.

PURPOSE: The aim of this study was to review our experience of nonunion of mandible fractures and to compare this information with the past and present literature. The analysis also evaluated risk factors and those conditions that lead to nonunion so that the complication may be better managed and possible avoided. PATIENTS AND METHODS: A retrospective review of mandible fractures in a major medical center was carried out on patients treated from 1994 through 1998. The nonunion cases were evaluated for factors such as age, sex, race, cause of fracture, location of fracture, delay until the patient obtained treatment, teeth in the fracture line, use of antibiotics, multiplicity of fractures, degree of fragmentation, medical problems, and drug and alcohol abuse. The adequacy of reduction and appropriateness of the fixation techniques were evaluated by analysis of the postoperative imaging studies. Postoperative occlusion and patient compliance were also included in the evaluation. RESULTS: Of the 906 patients with 1,432 mandible fractures, there were 25 nonunion complications, for an incidence of 2.8%. Most patients with nonunion were men who had received the fracture as a result of an altercation. The nonunion was frequently noted in the body, and was almost twice as common (39% vs 17.6%) in patients with multiple fractures than in a randomly selected group who did not have the complication. Delayed treatment was noted in 8 of the patients, and teeth were present in the fracture line in another 8. Alcohol and drug abuse were prevalent, and 1 of 5 of the patients removed their fixation devices. Eight patients were believed to be stabilized inadequately, and 1 patient also had a poor reduction. Osteomyelitis was a common complication. CONCLUSIONS: The incidence of nonunion appears to be unchanged over time regardless of the varied and presumably advanced methods of fixation and reduction. Multiple fractures were a contributory factor, and the body of the mandible appeared to be a common site. Many patients had osteomyelitis associated with the nonunion. Inadequate stabilization or reduction were important causes. Other suspected contributory factors included failure to provide antibiotics, delay in treatment, teeth in the fracture line, alcohol and drug abuse, inexperience of the surgeon, and lack of patient compliance.

Nonpainful swelling of the palate and loosening of the maxillary incisors.

Bone lesions in the maxilla have rarely been described in relation to sarcoidosis. This patient exhibited many of the classic signs of sarcoidosis, including lack of symptoms at the time of presentation, which resulted in the diagnosis of sarcoidosis being made serendipitously. The presence of musculoskeletal lesions is often regarded as a poor prognostic sign and, in general, sarcoidosis follows a more virulent course in black patients. Sadly, the course of the disease in this patient continues to march onward despite a 1-year therapeutic trial of corticosteroids.

Multiple segmental gradual distraction of facial skeleton: an experimental study.

The method of distraction osteogenesis was used to move several facial segments in different directions with formation of new bone. On 3 young adult sheep a Le Fort II osteotomy, combined with circumferential orbital osteotomies, was performed. The periosteum over the osteotomies was preserved. Titanium bone screws were placed as bone markers. The segments were fixed with pins and plates to a combined distraction apparatus in order to advance the segments in different directions. By a gradual distraction, the midface was advanced forward by 30 mm. The left orbit was moved laterally 20 mm and the right orbit was moved forward 20 mm. In both orbits there was a concomitant globe movement. New bone formation in the distracted area was obvious radiographically, clinically, and histologically. In conclusion, multiple segmental distraction is possible in the adult sheep face and may offer three-dimensional (3D), controlled correction of complex face deformities.

Midface advancement by gradual distraction.

Midface osteotomy was performed on 5 young adult sheep aged 10-12 months. In 4 animals midface advancement by gradual distraction was performed using an external device; one animal served as a control. The midface was advanced by 2 mm per day for 21 days. The amount of advancement was 36 mm in the nasofrontal area and 43 mm on the lateral aspect of the maxilla. After the period of active distraction the midface was maintained with external fixation for an additional 6 weeks to allow for ossification. Radiographs were obtained immediately postoperatively, after 21 days of distraction, and at the end of the 6 week fixation period. New bone formation in the distracted area was obvious radiographically, clinically and histologically. In conclusion, midface advancement by osteotomy and gradual distraction is possible in the sheep model and may offer controlled correction of deformity, obviating the need for the bone grafting.

Effects of exposure time and pulse parameters on CO2 laser osteotomies.

Two sets of experimental linear osteotomies were performed on frozen cortical bone by means of a high-power industrial CO2 laser in the rapid superpulsed mode, varying the velocity of the operating table, the mean power of the laser beam, the pulsewidth, the pulse repetition rate, and the peak power. Both the depth and the width of the osteotomies were inversely related to the velocity and directly related to the mean power and to the pulsewidth, but they were not affected by changes in the repetition rate. The depth/width ratio, which describes the profile of the osteotomies, was affected by the mean power only. These data permit greater accuracy in the planning of laser osteotomies in cortical bone when using the rapid super-pulsed mode.

Healing of continuous-wave and rapid superpulsed, carbon dioxide, laser-induced bone defects.

With rabbits as the experimental model, a comparative study was done to assess the healing of bone in response to osteotomy by rapid superpulsed and continuous-wave carbon dioxide lasers. The laser was capable of easily incising bone; the rapid superpulsed mode required less energy to do so than did the continuous-wave mode. When the narrow zone of tissue necrosis adjacent to the laser osteotomy was debrided, it was found that healing was similar for each laser mode. Healing occurred in orderly progression from deposition of trabecular bone to formation of lamellar bone.