Quantifying Aerosol Generation in Maxillofacial Trauma Repair Techniques

Study Design Cadaveric simulation study. Objective The novel coronavirus (COVID-19), which can be transmitted via aerosolized viral particles, has directed focus on protection of healthcare workers during procedures involving the upper aerodigestive tract, including maxillofacial trauma repair. This study evaluates particle generation at different distances from open reduction and internal fixation (ORIF) of maxillofacial injuries in the intraoperative setting to reduce the risk of contracting airborne diseases such as COVID-19. Methods Two cadaveric specimens in a simulated operating room underwent ORIF of midface and mandible fractures via intraoral incisions as well as maxillomandibular fixation (MMF) using hybrid arch bars. ORIF was performed with both self-drilling screws and with the use of a power drill for creating guide holes. Real-time aerosol concentration was measured throughout each procedure using 3 particle counters placed 0.45, 1.68, and 3.81 m (1.5, 5.5, and 12.5 feet, respectively) from the operative site. Results There was a significant decrease in particle concentration in all procedures at 1.68 m compared to 0.45 m, but only 2 of the 5 procedures showed further significant decrease in particle concentration when going from 1.68 to 3.81 m from the operative site. There was significantly less particle concentration generated at all distances when using self-drilling techniques compared to power drilling for ORIF. Conclusion Consideration of using self-drilling screwing techniques as well as maintaining physical distancing protocols may decrease risk of transmission of airborne diseases such as COVID-19 while in the intraoperative setting.

Recovery of Post-Traumatic Temporomandibular Joint after Mandibular Fracture Immobilization: A Literature Review

Considered as one of the most common traumatic injuries of the maxillofacial region, mandibular fractures remain among the complex causes of temporomandibular joint disorders (TMDs). Due to the complexity of the temporomandibular joint, the management of TMDs represents a challenge in real-life practice; although many treatment modalities have already been proposed, ranging from conservative options to open surgical procedures, a consensus is still lacking in many aspects. Furthermore, despite continuous improvement of the management of mandible fractures, the duration of immobilization and temporary disability is not reduced, and the incidence of complications remains high. The aim of the present study is to (i) review anatomophysiological components of temporomandibular joint; (ii) review concepts of temporomandibular joint fractures; and (iii) describe methods of the recovery of the temporomandibular joint after mandibular fracture immobilization.

Comparative evaluation of biting force in 2mm locking plates with 2mm miniplates in the treatment of mandible fractures: A clinical study

1. To compare efficacy of 2mm locking plates with 2mm miniplates in the fixation of mandible fractures and 2. To evaluate and compare the biomechanical function by measuring the bite force at 1st week, 3rd week, 6th week and 3rd month postoperatively in 20 patients divided equally into two study groups.A prospective randomized study was carried out at Department of Oral and Maxillofacial Surgery, Meghna Institute of Dental Sciences, Nizamabad from 2019 to 2021 to treat consecutive mandibular fractures where patients were randomly divided into two groups each composed of 10 patients where Group A were treated with single 4 holed stainless-steel locking miniplates and Group B with two 4 holed stainless steel conventional mini plates both maintaining a gap of 2.0 mm system. Later assessment was done using bite force recording postoperatively at 1st week, 3rd week, 6th week and 3rd month and with the associated complications like Swelling, Infection, Paresthesia, Mobility between fracture fragments and Hardware failure.When the mean bite force values in right molar region of group A and group B were compared at 1st week, 3rd week, 6th week and 3rd month, there was statistically significant increase in bite force noted in group A when compared to group B at 1st week and 3rd week (P<0.05). But no statistically significant differences were observed at 6th week and 3rd month (P>0.05).When the mean bite force values in the central incisor region of group A and group B were compared at 1st week, 3rd week, 6th week and 3rd month, there was statistically significant increase in bite force noted in group A compared to group B at 1st week and 3rd week (P<0.05). But no statistically significant differences were observed at 6th week and 3rd month (P>0.05).When the mean bite force values in left molar region of group A and group B were compared at 1st week, 3rd week, 6th week and 3rd month, there was statistically significant increase in bite force noted in group A when compared group B at 3rd week (P<0.05). But no statistically significant differences were observed at 1st week, 6th week and 3rd month (P>0.05).The study signifies that both the fixation systems were able to provide stability to fracture segments, but locking plate system has provided better stability when compared to miniplates system, hence recommending for more elaborative studies to arrive at definitive conclusion.

A review of biomechanical studies for mandibular angle fracture internal fixation

Mandible fractures correspond to 19-40% of all facial fractures. Among all mandible fractures, 12-30% are fractures of the mandibular angle. These fractures are mainly caused by sports activities, interpersonal violence and car accidents. The presence of the third molar and the thin transverse bone area seem to be responsible for the frequent involvement of the mandibular angle in facial fractures. Before the advent of antibiotics, a high frequency of infection was always associated after an open reduction in mandibular angle fractures. Wired osteosynthesis and maxillomandibular fixation (MMF) were traditional methods for fixing mandibular angle fractures. The limitation of both methods has influenced the development of new approaches for the treatment of mandibular angle fractures. Currently, osteosynthesis of mandibular angle fractures with plates and screws has become an effective treatment option. Several forms are described in the literature as: fixation of bone segments with a miniplate on the upper edge of the mandible, fixation with two miniplates, lag screw or by a single rigid plate on the lower edge of the mandible. The purpose of this study was to summarize the main characteristics of biomechanical studies such as the type of mandible source used, the plating techniques employed, the plate material, and the loading protocols used to evaluate the stability of the fixation methods. The Medline (PubMed) database was searched combining relevant terms and pertinent articles in English were included. Articles had to meet the following inclusion criteria: be in vitro biomechanical studies evaluating fixation methods for mandibular angle fractures. A total of 27 articles fulfilled the inclusion criteria. Synthetic mandibles (n=12), animal mandibles (n=9), and human cadaveric mandibles (n=5) were used as the sample source to perform the biomechanical analysis. One article used both synthetic and human cadaveric mandibles. Also, a variety of fixation techniques was described such as mini-plates, lag-screws, reconstruction plates, and three-dimensional plates. The materials of the bone plates used were: stainless steel, commercially pure titanium, titanium alloy or bioresorbable. However, there was inconsistency in reporting the materials and not all studies clearly stated the material of the bone plates. For the biomechanical analysis, there was a high variation among all studies regarding the loading protocols used. The same side of fixation, the anterior part of the mandible (central incisors) or the contralateral side were reported as the dentate regions in which the force was applied. For more than 2 decades, in vitro biomechanical studies have been used to help researchers and clinicians in the field of Oral and Maxillofacial Surgery to properly evaluate and compare the different devices and techniques available for the treatment of mandibular angle fractures. Also, biomechanical studies are important to answer questions on fatigue performance and fracture strength on the gross level.

1114 Getting it Right First Time: An Audit of Length of Hospital Stay for Mandibular Fractures

Introduction GIRFT is a Department of Health programme, created to improve efficiency by providing data that gives departments a national standard to encourage reflection and service-improvement. The 2016 document in Oral and Maxillofacial Surgery, suggests the national average length of stay for isolated mandible fractures was 2 days, 1 day pre-operatively and 1 day post-operatively. This Audit aimed to investigate if all admissions in our trust met this standard, as a short stay reduces costs and improves patient experience. Method Data was collected for all isolated mandibular fracture admissions between January – September 2019, with 89 patients identified. Date of admission, surgery and discharge was recorded which allowed calculation of pre-operative, post-operative, and total stay. Results 78% of patients had surgery within 24 hours of admission. Admissions on a Saturday were most often delayed, with a mean pre-operative stay of 1.60 days and total stay of 2.55 days. Commonly the reason for delay was not recorded, or due to lack of theatre space. 92% of patients were discharged within 24 hours post-operatively. The average length of stay met the 2-day standard, with Monday admissions having the shortest average stay of 1.45 days. Conclusions Whilst the majority of patients are treated and discharged within 2 days, improvements and future audit would assist to get closer to the 100% target. Saturday saw the highest number of admissions, which also had the longest average length of stay. A dedicated weekend trauma list would reduce wait times but may be limited by staffing and theatre space.

Prevention of Mandible Fractures in Medication-Related Osteonecrosis of the Jaws: The Role of Virtual Surgical Planning and Computer-Aided Design and Manufacturing in Two Clinical Case Reports

Background: Marginal mandible resection is required to achieve healing in some cases of medication-related osteonecrosis of the jaws (MRONJ). Despite the sparsity of the literature, computer-aided design/computer-aided manufacturing (CAD/CAM) materials may provide superior outcomes for patients with an increased risk of mandible fracture. The aim of this study was to report a digital workflow for surgical interventions to prevent mandible fracture in MRONJ patients. Methods: We present two cases in which virtual surgical planning (VSP) and CAD/CAM surgical guides and reconstruction plates were used to prevent mandible fractures in elderly MRONJ patients submitted for marginal resection. Two osteoporotic patients, aged 73 and 84 years, presented with stage 3 MRONJ of the right mandibular body with inferior alveolar nerve involvement. The unaffected bone height was 6 mm in both cases, implying a high risk of mandible fracture. After preoperative VSP, surgery was performed through a combined intraoral–transbuccal approach. CAD/CAM-customized cutting guides and reconstruction plates were used for the marginal resection of necrotic bone and internal fixation. Results: Complete healing was achieved and the patients remained asymptomatic up to 1 year post-surgery. Conclusions: VSP and CAD/CAM-customized materials facilitated the complete resection of necrotic bone and rigid fixation in MRONJ patients, allowing a simplified approach with shorter operative times, reduced morbidity, and predictable results.

Comparison of Preauricular Approach Versus Retromandibular Approach in Management of Condylar Fractures

Objectives: Surgical treatment of patients with multiple mandibular fractures involving condylar segments may be a difficult proposition for a maxillofacial surgeon. These fractures can be double or triple fractures of the lower mandible and can also be associated with other fractures of the face. While many authors have suggested that the conventional approach to reducing and stabilizing a mandibular symphysis / para-symphysis fracture is appropriate before addressing a fractured condyle, there is another school of thought that suggests that the condylar segment should be reduced and repaired first. This article aims to review the results of operations where the reduction and fixation of a fractured condyle is performed prior to other associated mandible fractures, and to explore the effectiveness of various surgical methods including preauricular and retromandibular proposed in this case. Place and Duration: In the Oral and Maxillofacial surgery department of Faryal Dental College, Lahore for two-years duration from Jan 2018 to Jan 2020. Material and methods: The study included 60 surgically treated patients with multiple mandible fractures (double / triple), including the condyle component. For treatment of the fractured condylar segments, the preauricular and retromandibular (anterior parotid-transmasseteric) approach was used. Results: Condyle fracture was the first segment to be managed during sequencing of surgical treatment, regardless of the method used. First, good reduction and stabilization have been achieved with limited complications in treating a condyle fracture. Conclusion: While it is the surgeon's prerogative to sort multiple mandible fractures, addressing the condylar segment first provides the operator with a viable alternative to the conventional technique. Key words: condylar fractures, multiple mandibular fractures, preauricular approach, retromandibular approach