MANDIBLE JOURNAL on complications andnew tratment option .pptx

intermuscular septum between the extensor carpi ulnaris and the extensor digiti minimi. After the muscular branches are ligated, retraction of the extensor digiti minimi radially exposes the PIA. With further dissection, the communicating branch with the AIA can also be identified. Flaps are transferred by transposition to the recipient site with direct incision or through a subcutaneous tunnel. The flap is inset without tension; the vascular pedicle must not be compressed. With a skin island of less than 6 cm, primary closure is possible. A larger skin island requires skin grafting.

1. JOURNAL A 4-YEAR MULTICENTRE AUDIT OF COMPLICATIONS FOLLOWING ORIF TREATMENT OF MANDIBULAR FRACTURES DR.P.PAVAN KUMAR

2. This is a multicentre study involving four OMFS centres . These centres were recruited based on the geographic location (north-, mid- and south-west Malaysia) Department of Oral and Maxillofacial Surgery, Sultanah Nora Ismail Batu Pahat Hospital, Ministry of Health Malaysia (Johor), Jalan Korma, Taman Soga, 83000 Batu Pahat, Johor, Malaysia Department of Oral and Maxillofacial Surgery, Taiping Hospital , Ministry of Health Malaysia (Perak), Taiping, Malaysia Department of Oral and Maxillofacial Surgery, Malacca Hospital , Ministry of Health Malaysia (Malacca), Malacca, Malaysia Department of Oral and Maxillofacial Surgery, Sultanah Aminah Hospital Ministry of Health Malaysia (Johor ), Johor Bahru , Malaysia Clinical Research Centre, Kuala Lumpur Hospital, Ministry of Health Malaysia, Kuala Lumpur, Malaysia

3. Received : 3 November 2018 Accepted : 15 February 2019 Published online: 25 February 2019 The Association of Oral and Maxillofacial Surgeons of India 2019 Correspondence : Sathesh Balasundram [email protected]

4. DISCUSSION UNDER INTRODUCTION METHODS SURGICAL TECHNIQUE RESULTS DISCUSSION CONCLUSION

5. INTRODUCTION Maxillofacial trauma patients frequently sustain fracture injuries to the facial skeleton, mainly caused by motor vehicle accidents (MVA), in the course of scuffles and falls . Traditionally , immobilisation of the fracture has involved closed reduction by some form of intermaxillary fixation (IMF ). However, in the last two decades, there has been a increasing trend towards rigid or semi-rigid osteosynthesis by means of plates . In skilled hands, consistently successful results have been reported .

6. Surgical treatment of mandibular fracture consists of osteosynthesis with miniplates , reconstruction plates, lag screws or resorbable plates . Two fundamentally different philosophies have evolved in the treatment of mandibular fracture using plates and screws. One , which believed that rigid fixation was sufficient to prevent interfragmentary mobility during active use of the mandible . Large bone plates with bicortical screws were used, and primary bone union by compression osteosynthesis was the goal of treatment .

7. Bulky plates, difficult adaptation, stress shielding, scar formation due to extraoral approach, more operating time and increased chances of nerve injury were its disadvantages . Second , in which advocated a modificationof Michelet et al.’s technique of mandibular osteosynthesis , which consists of monocortical juxta -alveolar and subapical osteosynthesis , without compression and without IMF. The plates were placed near the tension zone produced by physiological strain. Since then, miniplates have been the preferred fixation method in craniomaxillofacial surgery because of their relatively small size, adaptability , ease of placement and intraoral approach.

8. These miniaturised plates obviate the need for intermaxillary or external fixation, are said to be easy to apply and are associated with fewer complications . Because of their biocompatibility and flexibility, titanium miniplates have been advocated as the method of choice for facial fractures and in maxillofacial bone reconstruction . Bone plates and fixation techniques vary with the severity and location of a fracture, as well as ability and preferences of the surgeon . Bone plate thicknesses are on the order of millimetres ; actual dimensions vary by manufacturer, depending on the intended use of the plate, and additional plates can be used to provide added stability.

9. Nevertheless, controversies abound with respect to the use of miniplates , which also have a complication rate. Restoring a pre-traumatic occlusion and reduction in compression of sensory nerves are the common aims for optimalisation of function . Post-operative complications are related to the type of fracture, dislocation or displacement , unilaterality or bilaterality , other additional fractures of the mandible/maxilla and the chosen surgical treatment .

10. Common complications described are mandibular asymmetry, temporomandibular joint pain, dysocclusion , (transient) facial nerve paresis, wound infection, osteosynthesis failure, pseudarthrosis , orocutaneous fistulae, plate infection, osteomyelitis, delayed union, nonunion, malunion , and inferior alveolar or marginal mandibular nerve injury due to surgical manipulation The need for a secondary operative intervention is rare but sometimes necessary, mainly to correct occlusal derangement and surgical site infection.

11. Reason for Study This study is aimed to ascertain the types of complications and associated features arising from open reduction and internal fixation (ORIF) of mandibular fractures and to elucidate if different osteosynthesis plating systems vary in treatment outcome

12. METHODS This is a multicentre study involving four OMFS centres . These centres were recruited based on the geographic location (north-, mid- and south-west Malaysia) and on the viability of conducting the study conjointly.

13. Inclusion Criteria 1. All mandibular fracture cases that were treated with surgical intervention (open reduction internal fixation). 2. Patients treated within the duration from 01/01/2009 to 31/12/2012 . 3. Patients who were solely treated in the participating centres .

14. Exclusion Criteria 1. All cases that were ‘jointly managed’ by other nonparticipating oral and maxillofacial surgery centres . 2. Cases which were lost to immediate follow-up following ORIF procedures. 3. Paediatric patients with mixed dentition.

15. Procedure All patients who sustained the mandibular fracture injuries and were treated surgically (ORIF) and met the criteria of this study were identified: 1. All clinical notes and patient records ( radiographs) were retrieved and assessed. 2. Pre-operative and post-operative assessment data were collected and collated. 3. Follow-up intervals were recorded and analysed accordingly.

16. Miniplates were not routinely removed after attainment of bone healing unless symptomatic; details of the plating system and all related complications were recorded. The osteosynthesis miniplate system utilised in this study comprised of titanium noncompression , nonlocking plates with 2.0-mm-diameter nonlocking monocortical screws .

17. Operative procedure Fixation Technique All procedures were performed under general anaesthesia in compliance with Champy’s principles of fixation of mandibular fractures .

18. Data to be Collected (a) Patients’ demographic details (b) Fracture details— aetiology , site, severity, multiple/ comminuted , displaced/not, associated dentoalveolar injury , tooth in line of fracture, laceration/tissue loss at site of fracture (c) Surgery details—surgical approach, date of trauma, date of ORIF, intraoperative complication, degree of displacement (pre-op ).

19. (d) Degree of local contamination. Mild Contamination that can visibly be cleaned with no obvious ‘left-over’ foreign debri Severe Extensive contamination whereby thorough debridement is not feasible or contaminants are deeply/widely embedded within tissue,

20. (e) treatment opted: ( i) ORIF alone (ii ) ORIF and closed reduction ( iii) ORIF and conservative (closed fracture that was not indicated for surgical intervention). (f) ORIF details—plating system used (g) Details of peri -operative medication—antibiotics details.

21. (h) Complication (i) Plate fracture (ii) Surgical site infection (iii) Plate exposure (iv) Post-ORIF displacement of fracture (v) Screw loosening (vi) Malunion /Delayed/nonunion of fractures (vii) Wound dehiscence/breakdown (viii) Nerve injury—hypoesthesia, paraesthesia (ix) Others suture granuloma, scarring

22. Complication onset period was categorised as follows: ( i) Early from time of surgery to 6 days ( ii) Intermediate from 1 week to 6 weeks postoperatively ( iii) Late from after 6 weeks post-operatively

23. (i) Occlusion (post-op ): Good Functional occlusion that is free of interferences to smooth gliding of the mandible and discerned as normal ( pretrauma ) occlusion by the patient and clinician Mild Derangement Acceptable variation from patient’s pretrauma occlusion , might or might not be discernable to the patient, but detectable to the clinician Severe Derangement An obvious discrepancy in patient’s occlusion discernable to both clinician and the patient, necessitating a re-intervention (open/closed reduction ).

24. RESULTS Review of this cohort database identified 593 patients , ( 88% male, 12% female), ranging in age from 19 to 32 years (median = 22 years). The follow-up time to December 2012 ranged from 30 to 230 days ( median 72 days)

25. This study revealed that the most common site of mandibular fractures was parasymphysis (50.1%), angle (35.2 %) and body of mandible fractures (25%). Only 42.5 % of patient sustained isolated unilateral fractures, whereas more than 50% of the patients sustained multiple, bilateral or comminuted fractures. 54 % of the patient sustained concomitant head injuries and/or midface fractures. The most frequently used plating systems were Synthes Compact (62.2%) and Stryker Leibinger (24.5%). The interval between time of injury to time of surgical intervention ranged from 4 to 10 days (median = 7 days).

26. As far as complications are concerned, a total of 137 patients (23.1%) had one or more complications . Most complications (46%) occurred in the intermediate post-surgical period (1–6 weeks). Median interval period between surgery and complication was 15 days. The most common complication was noted to be nerve injury (6.7%) and surgical site infection (5.7%)

27. Patients with angle , body and bilateral parasymphyseal fractures were more prone to have complications. There was a significant difference between the plating system in terms of complication outcome (p = 0.017) . Patients with concomitant midface fractures , bilateral condylar fractures , bilateral parasymphysis fractures and with tooth in the line of fracture were more likely to have occlusal derangement. patients with angle and bilateral parasymphysis fractures and with soft tissue laceration at the fracture site were more likely to have surgical site infections post-operatively.

28. DISCUSSION Our study demonstrates the high prevalence of motor vehicle accident-related mandibular fractures, mainly involving males, consistent with Malaysia’s high number of motorcycle-related crashes and fatalities, with 1,20,156 reported crashes and 4,036 deaths in 2010 . In the past, IMF was considered the first line of approach for mandibular fractures in many OMFS centres in Malaysia. At present, most centres offer open reduction in fractured mandibles as the preferred option. Complications related to the management of mandibular fractures in these centres were keeping with complication rates published in other centres .

29. The diversity in treatment options results in many treatment-related complications. Titanium osteosynthesisplates being biocompatible, resistant to corrosion and complying with the mechanical properties needed have been considered as the material of choice in maxillofacial traumatology . Consequently, plates are removed only when there is a clinical indication. Plate- and screw-related complications in this study were recorded at 6% (n = 36) in this series, and 5.7% (n = 34) of our patients had surgical site infection.

30. Whilst wound-healing disturbances and infections account for the major part of complications, the etiologic background of a fracture collective provides hints about social background, smoking, alcohol consumption, oral hygiene and compliance.

31. Superficial infection, plate exposure and screw loosening were the principal reasons for plate removal in this study. This concurs with other authors who found infection to be the main cause of plate removal . As has been mentioned , most clinical papers do suggest removal only of symptomatic plates. ‘The Strasbourg Osteosynthesis Research Group provided the following recommendations at their symposium held in the Netherlands 1991 : A platewhich is intended to assist the healing of bone becomes a nonfunctional implant once this role is completed .

32. The removal of a nonfunctional plate is desirable provided the procedure does not cause undue risk to the patient. Brown et al. reported that there was no relationship between the site of the plates and their need . However, in Rallis et al. [23] series, the nasofrontal area, the anterior wall of the antrum and the body of the mandible were ‘ high risk ’ sites needing plate removal, whilst the frontozygomatic suture was a site of low risk. This is consistent with our data that also reveals the highest incidence of wound dehiscence in the body of mandible.

33. Sensation alterations are often observed in mandibular fractures . The main cause for sensory nerve abnormalities in mandibular angle fractures is the degree of displacement of the segments. During surgery, aggressive manipulation due to fracture replacement may cause additional nerve injury, sometimes , drill hole preparation near the mandibular canal may also cause permanent alterations.

34. In our cohort, angle and parasymphyseal fractures were more frequently associated with nerve injury . This finding is not surprising due to the close proximity of the fracture sites to the inferior alveolar nerve and the mental nerve.

35. In our series, the complication of occlusal derangement was recorded at 5.1% (n = 30). This complication was more prevalent among patients with multiple mandibular fractures and in those with concomitant midface fractures and tooth in the line of fracture.

36. As far as the osteosynthesis plating systems were concerned, the difference in related complications among the systems is a finding that needs further clarification and randomised studies. As the systems used vary between centres and different surgeons have their preferred system, there is a selection bias in this study which cannot be excluded .

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