Extraoral Approach Research Articles

Limiting antibiotic prophylaxis in the treatment of maxillofacial fractures: A retrospective, single-center study of 81 patients

IntroductionThe aim of this study was to investigate the validity of the duration for which we provide antibiotic prophylaxis to maxillofacial fracture patients who undergo open reduction and internal fixation (ORIF) in our hospital by retrospectively reviewing the incidence of surgical site infections (SSIs). MethodsThe medical records of 83 patients with maxillofacial fractures who underwent ORIF from April 2010 to October 2019 were retrospectively reviewed. The surgeon selected the proper surgical approach to the fracture site depending on the location and type of fractures. ORIF was performed by an intraoral, extraoral, or transconjunctival approach, or a combination of these approaches. No statistical investigation of differences in the method of prophylactic antibiotic administration and the occurrence of SSIs was conducted because of the small sample size. ResultsThis retrospective study included 81 patients (58 males; median age 41 (range: 13–82) years; median BMI 22.4 (range: 16.5–33.6) kg/m2) with maxillofacial fractures. Two patients with infected fractures before operation withdrew from this study. The most common choice of antibiotic prophylaxis was cefmetazole for 2 days, followed by cefmetazole for 1 day. Two patients were diagnosed with an SSI; one was on cefazolin 2 g for 2 days, and the other was on cefmetazole 2–4 g for 2 days. In both cases the infection was successfully controlled, and implant removal was not required. ConclusionsIn principle, antibiotic prophylaxis for 2 days postoperatively is sufficient in ORIF for maxillofacial fracture, but a multicenter, prospective, randomized study may be required to confirm this.

Intraoral and extraoral approach for surgical treatment of Eagle's syndrome: a retrospective study.

Eagle's syndrome is not uncommon in clinical work. Because of its atypical symptoms, it is easy to be misdiagnosed as other diseases, further leading to misdiagnosis and mistreatment. At present, there is no expert consensus or treatment guidelines for the disease. We evaluated the clinical characteristics and postoperative efficacy of 103 patients with Eagle's syndrome based on their clinical symptoms, radiological studies, and physical examination. Through the multicenter clinical study of Tongji Medical College and Dalian Medical University, we found some characteristics of Eagle's syndrome in operation and imaging. In total, 103 patients with Eagle's syndrome (treated from January 2010 to January 2020) were retrospectively enrolled. The postoperative curative effect was analyzed by three surgical methods: styloid process resection through the external cervical approach (styloid process could not be touched through the mouth or could be touched under the jaw or when the CT scan showed that the inclination angle was not large), tonsillectomy + styloidectomy, and preservation of the tonsil for styloidectomy (the styloid process bone could be touched directly during intraoral palpation or in whom the distal part of the styloid process could not be directly touched, but the CT scan showed that the bone inclined toward the oropharynx and its distal part was relatively close to the oropharynx cavity; whether tonsillectomy was performed depended on whether the patient's tonsil was too large to affect the surgical incision). According to the Quality of Well-Being Scale (QWB), we calculated the W value of the scale before operation and 30 days, 3 months, 6 months and 12 months after operation, and compared the W value of each group. The average length of the styloid process was 33 mm (range 25-61 mm). The patients were followed up for 12-36 months (average 15 months). Of the 103 patients, 21 underwent styloid process resection through the external cervical approach, 49 underwent tonsillectomy and styloidectomy, and 33 underwent styloidectomy with preservation of the tonsil. The treatment cured 48 (46%) cases, was effective in 35 (34%) and was ineffective in 20 (20%). The R language 3.6.3 software was used to perform the nonparametric rank sum test, differences in characteristics between groups were analyzed using the Kruskal-Wallis test with Dunn post hoc tests ( R package FSA) for categorical variables, and there was no significant difference between the three types of operations (H = 0.491, P = 0.782). QWB showed that the quality of life after operation was improved compared with that before operation. Operation is an effective method for treating Eagle's syndrome. There were no significant differences between the effects of the intraoral and external cervical approaches. Imaging examination-especially CT scanning and 3D reconstruction of the styloid process-is very helpful for diagnosis, but not an absolute criterion for the selection of surgery protocol.

The Effect of Application of Combined Bovine-Derived Anorganic Bone Graft and Hemostatic Plant Extract on Bone Regeneration.

To evaluate the effect of bovine-derived anorganic bone graft (ABB) in combination with hemostatic plant extract (ABS) on bone regeneration. Three bone defects were created via an extraoral approach on the mandibles of nine domestic pigs. The first defects were filled with ABS solution (0.3 mL/defect) in a transporting agent of ABB (0.3 cc/defect), whereas the second defects were filled with ABS (0.3 mL/defect) in microcapsules for controlled drug release, combined with ABB (0.3 cc/defect) again. The third defects were left empty. After a 10-week healing period and the sacrification, undecalcified sections were prepared for histomorphometric analysis. The mean total area of hard tissue was 29.54% ± 3.2% in the control group, 59.78% ± 5.4% in the conventional group, and 63.67% ± 4.2% in the microsphere group (P < .001). The mean area of newly formed bone was 29.54% ± 3.2% in the control group, 34.79% ± 3.9% in the conventional group, and 37.95% ± 5.3% in the microsphere group (P = .003). The mean residual graft area was 24.99% ± 2.4% in the conventional group and 25.71% ± 4.4% in the microsphere group (P = .730). The combined usage of ABS and ABB in both ways increased bone regeneration statistically. However, there was no significant difference between the two methods for ABS delivery systems in terms of new bone regeneration.

Ectopic third mandibular molar: evaluation of surgical practices and meta-analysis.

To identify the preferred surgical approach (intra- or extra-oral) to remove an ectopic third mandibular molar (ETMM) according on its location and presence of an associated cyst or cutaneous fistula, and to determine the indications for a graft or osteosynthesis. A surgical practice questionnaire was distributed to oral and maxillo-facial surgeons attending a National Congress of the French Society of Stomatology, Maxillo-facial and Oral Surgery. A systematic review of the literature and meta-analysis was carried on Pubmed, Cochrane, Embase and ScienceDirect databases using the MeSH terms: "Ectopic teeth", "Third molar", "Mandibular". One hundred and forty-three surgeons answered the questionnaire and the meta-analysis included 66 articles. From the questionnaire, the preferred surgical approach was intra-oral except when the ETMM was in the condyle, when it was extra-oral (69.5%; p < 0.001). In the meta-analysis, an extra-oral approach was only indicated when a cutaneous fistula was present (90% vs. 35.9%; p = 0.002), irrespective of ETMM location. In the questionnaire and meta-analysis, the presence of a cyst did not change the approach (p < 0.05). The indications for a graft or osteosynthesis were a condylar location (p < 0.001), while a cutaneous fistula decreased the indication (p = 0.04) and a cyst (p = 0.009) was only associated with a graft. The preferential approach was intra-oral, except when the ETMM was condylar or a cutaneous fistula was present when an extra-oral approach was preferred. Osteosynthesis or a graft were more likely when the ETMM was in the condyle. This study will help to orientate surgeons vis-à-vis ETMM treatment.

The Bulky Dermoid Cyst of the Floor of the Mouth

Bulky dermoid cysts of the floor of the mouth are very rare and may induce functional disorder. We present a 68-year-old Chinese woman who presented a painless swelling in right mandibular. Physical examination revealed a painless, soft, poor mobility, doughlike mass swelling which was reached to the floor of the mouth, and MRI showed a circumscribed mass of about 20.0×10.0×12.0 cm size. After complete excision of the cyst through an extraoral approach, histology diagnosed dermoid cyst. Dermoid cyst is uncommon found in the floor of the mouth, where there is a soft, painless, associated dyspnea, dysphagia and dysarthria. Imaging may assist diagnosis. Definitive diagnosis is founded on the histology specimen. According to the location and size of the cyst on each occasion, enucleation via intraoral or extraoral approach will be chosen treatment for cyst in the floor of the mouth. Although malignant degeneration of dermoid cyst of the floor of mouth is extremely rare, there are also such a situation reports. Thus, it is important to remove a cyst before the opportunity for malignancy.

A Clinical Re-Evaluation of an Unexplored Technique for Post Gap Arthroplasty Retrognathic Mandible.

The current manuscript explores the viability of reverse sagittal split osteotomy technique for correction of ankylotic cases with post gap arthroplasty mandibular retrognathia to achieve socially acceptable esthetic results. Reverse sagittal split osteotomy which was introduced by Collins et al in 1983 was performed with certain modifications on two cases to correct mandibular hypoplasia in post gap arthroplasty cases. The paper also highlights intraoral as well as extraoral approach for performing the osteotomy along with better management of bad split under direct vision. It was observed that the reverse sagittal split technique for advancement of mandible in cases of tmj ankylosis-induced dentofacial deformity provided better proximal control, reduced chances of bad split, greater range of advancement (11-14 mm) with esthetically acceptable results. The osteotomy cuts on lateral surface of mandible make the procedure effectively easier and quicker with better control over proximal segment and management under direct vision. When Distraction Osteogenesis and conventional orthognathic is not a choice in management of dentofacial deformity of post-release ankylosis cases due to the poor proximal control and concern over bad split, reverse sagittal split can be an appropriate choice to manage these deformities without any donor site morbidity.

Analysis of facial nerve function after open reduction of mandibular condylar fracture via a retromandibular approach

Mandibular condylar fractures account for a sizeable segment amongst facial fractures. Previously most of these fractures were managed conservatively with periods of Intermaxillary fixation(IMF). Shortcomings of such an approach such as prolonged pain, Tmj dysfunction and delayed return to function has shifted the discourse to open reduction and internal fixation of the fractured mandibular condyle.ORIF is the universally accepted and mainstay of intervention. Numerous extra oral approaches have been employed with various modifications. The retromandibular transparotid approach is a relatively simple and direct approach to the posterior mandible, enabling the surgeon to deal with sub condylar and condylar neck fractures with relative ease. This approach is a safe approach and does not result in permanent palsy of any of the branches of the facial nerve. To analyse facial nerve function after ORIF of mandibular sub condylar fractures through the retromandibular transparotid approach. 25 patients reporting with unilateral condylar fractures, sub condylar (16) and neck fracture (9) (Ellis classification)consenting for the study were taken up. All patients were followed up for 8 months. Post-operative nerve function was evaluated at 24 hours after surgery, 1,4,12 weeks and at the end of 8 months. 4(16%) patients presented with weakness of the facial nerve. Buccal branch (3) and zygomatic branch (1). In all cases the weakness was temporary and no permanent deficit was noted.

In vivo testing possibilities of periodontal biomaterials with intra-oral and extra-oral approaches on laboratory rats

Introduction Periodontitis is an oral inflammatory disease of significant importance, that leads to gingival inflammation, alveolar bone loss and has a high impact on the quality of life and general health. There has been a continuous interest in the scientific world to test new therapies and therapeutic materials for periodontal disease. One of the most critical tools to investigate mechanisms of periodontal pathogenesis and test new therapeutic materials are animal models. In addition, there is a wide range of materials used in periodontal therapy, especially in terms of bone augmentation, so choosing the ideal material is often difficult to achieve. Methodology In this article, we have evaluated two methods for testing artificially induced periodontal defects - intra-orally and extra-orally - the biological adaptation of the materials used in periodontal and bone regeneration techniques on animal models. Results We have created two protocols for the extra-oral and intra-oral approaches. By following them we have succesfully managed to create the periodontal defects and to apply the therapeutic materials. We have also made a comparison between the two methods, and the possibilities of materials that can be used. Conclusion Tests performed on animal models will remain an important asset for evaluating new approaches for the improvement of tissue regeneration therapies. As there are continuous advances in the study of dental materials, we also have to search for new, easy to perform, ethics-friendly methods to evaluate the biological response of these materials.

Periangular transmasseteric infraparotid approach in the treatment of condylar-base and low condylar‑neck fractures

Mandibular condylar fractures account for 25 to 52 % of all mandibular fractures. Though current literature favors open reduction and internal fixation (ORIF) of condylar‑base and low condylar‑neck fractures, extraoral approaches are usually considered to be complicated by the risk of facial nerve injury and other possible complications. This study was undertaken to demonstrate that the periangular transmasseteric infraparotid surgical approach (TMIP) to condylar‑base and low condylar‑neck fractures provides excellent access to the bony fragments with minimal risk of complications such as facial nerve and parotid gland injury. In the period from January 2010 to December 2018, 81patients (96 fractures) with condylar‑base and low condylar‑neck fractures underwent ORIF via periangular transmasseteric infraparotid surgical approach. The results of this retrospective study showed minimal postoperative complications. The periangular transmasseteric infraparotid surgical approach allowed precise anatomic repositioning and fixation of the bony fragments in almost all cases except for two juvenile cases with noticeable scars and one case with plate fracture. There were no transient or permanent facial nerve palsies, parotid gland or salivary fistulae complications during a 12‑month follow‑up period. The periangular infraparotid transmasseteric approach to ORIF of condylar‑base and low condylar‑neck fractures is an effective and safe approach allowing accurate anatomic reposition and fixation of the fragments with minimum surgical complications (Tab. 1, Fig. 12, Ref. 21).

Condilectomía baja intraoral para el tratamiento de Hiperplasia Condilar Reporte de un caso

ABSTRACT Condylar hyperplasia is a developmental malformation that causes abnormal growth of the mandibular condyle. It is a generic term that describes conditions that cause excessive growth and elongation of the mandibular condyle, altering the occlusion and indirectly affecting the maxilla. The usual treatment for this pathology consists of a condylectomy through an extraoral approach. The objective of this work is to present the case of an active unilateral condylar hyperplasia, which was treated by low condylectomy with an intraoral approach and orthognathic surgery. The intraoral approach to a condylectomy has been poorly documented; however it offers numerous advantages and can be performed safely.

Comparative study between three different plating techniques in management of mandibular angular fractures. A Retrospective Study

Aim of Study: was to compare both clinically and radiographically between the three-dimensional plates, 2.4 reconstruction plates and superior border Champy's single miniplate fixation in the treatment of mandibular angle fractures. Materials and Methods: The study enrolled patients who suffered from mandibular angle fractures, presented to the outpatient clinic of the oral and maxillofacial surgery department, faculty of dentistry, October 6 University as well as to the emergency unit of October 6 University Hospital. Patients were divided into 3 equal groups; Group I where open reduction and internal rigid fixation (ORIF) was performed by using 3 Dimensional miniplates through an intra-oral approach assisted by transbuccal trocar. Group II where ORIF was performed by 2.4 reconstruction plate through an extra-oral Risdon approach. Group III where ORIF was performed using single superior border Champy's miniplate through an intra-oral approach. Follow up were scheduled 1 week then 1,3 and 6 months post-operatively. Intra-operative outcomes included: ease of accessibility, ease of adaptation, need for post-operative IMF and approach related complications. Results: Statistical analysis of this study concluded that (Group I) presented statistically significant lower infection rate and lower possibility of sensory and motor nerve affection (Group I) and (Group II) presented proper occlusion, more segment stability and fracture rigidity in the treatment of mandibular angular fractures in comparison to (Group III). Conclusion: The 3D plates demonstrated a superior advantage over the 2.4 Reconstruction plates of ease of insertion transbuccally avoiding any extraoral cutaneous scars, lower infection rates and negligible possibility of facial nerve affection.

Extraoral and Intraoral Treatment Approaches in Management of Mandibular Fractures

Extraoral and Intraoral Treatment Approaches in Management of Mandibular Fractures

Management of Atrophic Mandibular Fractures in Pakistan – Changing Trends with Preference to Extra-Oral Approach

Background: With the ever-increasing incidence of facial trauma in geriatric population, it is very important to improve the care given to these patients. This study has been focused on determining a better approach for management of atrophic mandibular fractures. &nbsp;Objective: To compare the frequency of complications of extra-oral versus intra-oral approach for the management of atrophic mandible fractures. Study Design: Randomized control trial. Settings: Outdoor patient of department of Oral and Maxillofacial Surgery, Mayo Hospital, Lahore Pakistan. Duration: One year, 20th January, 2018 till 20th January, 2019. Methodology: Seventy consecutive patients were included in this study from the OPD of Oral and Maxillofacial Surgery. All the patients were randomly assorted in the both groups, group A being the intra-oral approach and group B being the extra-oral approach. The outcome was determined on the basis of presence or absence of mal-union or non-union after the fractures were treated. Results: The mean age of cases in extra and intra oral group was 76.54±8.13 years and 73.66± 8.04 years. In extra-oral group, there were 21(60%) male and 14(40%) females and in intra-oral group, there were 25(71/4%) male and 10(28.6%) female cases. In extra –oral group 3(8.6%) cases had complication and in intra-oral group 2(5.7%) cases had complications, the frequency of complication in both groups, p-value &gt;0.05. Among complications in extra-oral group 2(5.7%) cases had non-union and 1(2.9%) had malunion and in intra-oral group 1(2.9%) cases had non-union and malunion each. The frequency of type of complication was statistically same in both group, p-value &gt;0.05. &nbsp;Conclusion: The incidence of complications is statistically same in both groups. Hence, we encourage the use of extra-oral approach for management of atrophic fractures of mandible.

Excision of Extensive Orbitozygomaticomaxillary Complex Tumors Combining an Intra- and Extraoral Approach With Transpalpebral Orbital Exenteration.

The junction of the bones of the orbit, caudal maxilla and zygoma intersect to form an anatomically intricate region known as the orbitozygomaticomaxillary complex (OZMC). Given the critical role of the OZMC in the structure, function and esthetics of the skull and midface, tumors in this region present unique challenges to the oromaxillofacial surgeon. Attempts to achieve histologically clean tumor margins in a cosmetically pleasing manner requires excellent intra-operative visualization. Additionally, minimized intra-operative and post-opertive complications is of paramount importance. In this manuscript we describe a combined intra- and extraoral approach to extensive tumors of the OZMC that incorporates orbital exenteration as a technique, which allows for excellent intra-operative visualization and mitigate intra- and post-operative complications. In addition, we describe our experience utilizing the technique in five clinical cases.

A case report of isolated zygomatic arch fracture by modified towel clip method

AbstractFractures of the zygomatic arch may be treated with a variety of techniques. The disadvantages of these methods include the difficulty of reaching the fracture site via the intraoral approach and the high level of surgical invasiveness associated with the extraoral approach. This is a case report. A 20‐year‐old man was banged on the face. He presented at our department complaining of a change in facial shape and difficulty in mouth opening. Modified towel clip method was used to treat the zygomatic fracture which was classified into Yamamoto Class II type, and successful reduction was achieved. We believe that this method is very effective from the standpoint of minimum invasiveness and simplicity.

Applied Anatomy of the Maxillofacial and Mandibular Regions of Indian Mithun (Bos frontalis) and its Clinical Significance in Regional Anesthesia

Background: The topographic and morphometric anatomy of various foramina provides an easy approach in performing nerve blocks by their proper tracking for regional anesthesia in surgical interventions. There is no previously reported information on the applied anatomy and clinical significance of the maxillofacial and mandibular regions of the Indian mithun. The present study was designed to provide important clinical landmarks related to tracking of the infraorbital, mental and mandibular nerves with its clinical significance in regional anesthesia in mithun. Methods: The study was conducted on the maxillofacial and mandibular regions of twelve (n=12) adult Indian mithun of either sex (n=6, male and n=6, female). The head region samples of naturally died mithun were collected from different parts of the Mizoram and Nagaland state of India and processed as per the standard maceration technique. Altogether, a total of twelve measurements were taken in the maxillofacial and mandibular regions of mithun by using a digital vernier caliper and the results were expressed as mean±standard deviation. The obtained parameters from the present study can be useful for an extraoral and intraoral approach for nerve block of the infraorbital, mental and mandibular nerve in the maxillofacial and mandibular regions of mithun. Result: The present study revealed that all the obtained parameters related to regional anesthesia showed a significant statistical difference (P less than 0.01** and P less than 0.05*) between the males and females of mithun. It can be concluded from the present study that the various applied parameters of the present study will aid the clinicians in the implication of regional anesthesia in the head region of mithun.

Outcomes of extra oral versus intraoral approach for Mandibular angle fracture reduction

Abstract&#x0D; Objective: To compare the outcomes of intraoral versus extraoral approach in the treatment of mandibular angle fracture.&#x0D; Method: The randomised controlled trail was conducted at the Department of Maxillofacial Surgery, Mayo Hospital, Lahore Pakistan, from September 2016 to March 2017, and comprised patients of mandibular angle fracture who were divided into two equal extraoral group A and intraoral group B. . Baseline and post-operative data on 1st and 7th days as well as 3 months following the surgery was collected. Data was analysed using SPSS 20.&#x0D; Results: Of the 100 patients, there were 50(50%) in each of the two groups. Mean age of group A was 32.28±7.79 years compared to 33.72±8.13 years in group B. There were 39 (78%) males in group A and 36(72%) in group B. The mean pain score at baseline in the groups was not significantly different (p=0.795). On the 7th day and 3 months post-operation, mean pain score was significantly lower in group A (p=0.002). Nerve complication in group A was significantly high compared to group A (p=0.005).&#x0D; Conclusion: Extra oral approach for the management of mandibular angle fracture is better with regards to pain while intra-oral approach is less associated with nerve complications.&#x0D; Key Words: Angle of mandible, Fracture, Intraoral approach, Extraoral approach, Incision.

SURGICAL TREATMENT OF EXTENSIVE CENTRAL OSSIFYING FIBROMA

A female patient, 22 years old, presented in our clinic complaining about a lump in her mouth and pain in her jaw. During the intake she reported that she had noticed these changes about 5 months ago. She denied other diseases, habits, or addictions. Physical examination verified facial asymmetry with swelling in the submandibular region and the right gingiva, with a posterior lobby fund of the mandible associated with areas of ulceration due to occlusal trauma. Through radiographic imaging, an extensive lesion was found which affected the posterior region of the right mandible. An incisional biopsy was performed which revealed a central ossifying fibroma. Preoperative examinations were requested and a surgical excision of the lesion was proposed with immediate reconstruction with iliac graft with an extra oral approach. The surgery was performed without complications. The patient is in observation for 1 year and is scheduled for implant rehabilitation.

Open Reduction and Internal Fixation Strategy For Treatment of Comminuted Mandibular Fracture.

The aim of this study was to evaluate the treatment strategy of open reduction and internal fixation (ORIF) for comminuted mandibular fracture (CMF). Clinical studies about CMF were collected. Detailed information was extracted, and data were analyzed and merged from included articles. Twelve studies, including 338 patients with CMF, were reported. A total of 256 patients receive ORIF among these 338 patients, and exhibited followed characteristics: ORIF usually were performed several days after injury; the extraoral approach for ORIF was used for 103 patients among 205 patients who received ORIF with definite information about surgical approach; titanium mesh, or reconstruction plate, combined with mini-plates was used in 17 and 194 patients, respectively; intermaxillary fixation (IMF) usually persisted about 1 to 3 weeks after ORIF; most patients exhibited satisfactory effect without serious complications, and the complication rate varied from 0 to 42%. ORIF strategy for treatment of CMF including: ORIF was a priority choice for CMF. ORIF usually was performed at several days after injury. Reconstruction plate, or titanium mesh, combined with mini-plates was recommended for ORIF surgery. After ORIF, IMF usually was recommended for about 1 to 3 weeks.

Endoscopically Assisted Treatment of Condylar Base and Neck Fractures: A Single Institution Analysis of Outcomes and Complications.

Conservative treatment, including observation and closed treatment, as well as open reduction and internal fixationare existing options for treating condylar process fractures. Extraoral approaches are widely preferred for open reduction and internal fixation. Transoral access for condylar base and neck fractures is not yet commonly used as it is technically demanding and requires special equipment. In this study, the transoral endoscopically assisted approach is described, and its outcomes and complications were investigated. Imaging data and clinical records of 187 patients with condylar process fractures, treated via endoscopically assisted transoral approach between 2007 and 2017 were analyzed. Parameters included diagnosis and fracture classification, treatment, osteosynthesis configuration and postoperative complications. Early complications, including infection, transient postoperative malocclusion, pain and limited mouth opening, occurred in 35 patients (18.7%). Late onset complications, such as screw loosening were documented in only 4 patients (2.1%). Revision surgery following postoperative 3D imaging was required in only 3 cases (1.6%). Fragment length ranged from 15.5 to 38.3mm. In 57.7% of patients with condylar fragment length < 20mm, a single osteosynthesis plate was used, with no elevated complication rate. Two osteosynthesis plates with 4 screws each was used as standard in longer fragments. Endoscopically assisted transoral treatment of condylar process fractures is a reliable, yet technical demanding technique. It allows for reduction and fixation of fractures with a condylar fragment length of > 15mm with low postoperative complication and revision rates.