Parasymphyseal Region Research Articles

A comprehensive study on maxillofacial trauma conducted in Yamunanagar, India

:Background:The Department of Oral and Maxillofacial Surgery, D.A.V [C] Dental College and Hospital, Yamuna Nagar, Haryana, India conducted a study on patients with maxillofacial fractures in a time span of seven years (2003-2010). The purpose of this study was to evaluate their aetiology, incidence, patterns and different modalities employed for management.Methods:In this study, 740 patients with 1054 fractures were evaluated clinically and radiographically, based on which closed reduction and open reduction was undertaken. Review of patient records included: Age, sex, time, mechanism and etiology of injury, history of bleeding, unconsciousness and prior first aid, type of vehicle and use of preventive measures, type of fracture and treatment modalities. Results:Road traffic accidents accounted for highest number of fractures predominantly occurring in the age group of 21-30 years (38.3%)1,2. Males incurred more fractures with a male female ratio of 4.2: 1.Mandible was the most commonly fractured bone with parasymphysis being the commonest affected site.76.66% patients had associated head injury and 15.68 % had history of unconsciousness. Open reduction and internal fixation was the preferred modality for mandible whereas the mid face fractures were treated more often by closed methods.Conclusions:Injuries occurred more commonly in 20 – 40 age range with road traffic accident being the major etiological factor. Majority of the patients were driving two wheelers and most were under the effect of alcohol. Most of the injuries occurred during night and road traffic accidents (71.89%) were found to be the major etiological factor. Out of 532 road traffic accidents, 490 patients (66.2%) were on two wheelers, among whom 49(10%) were wearing helmet. In the mandible, fractures occurred most commonly in the parasymphyseal region (224, 30.2%), and out of the 314 fractures of the middle third showed, 155 (49.4%) ZMC. OPG was the most commonly advised X-ray. With regard to treatment modalities, 36.8% of all the mandibular fractures (740) were treated by closed reduction, 62.6% were treated using open reduction and 0.5% was under observation only.

Miniplate Fixation of Fractures of the Symphyseal and Parasymphyseal Regions of the Mandible

To review our experience with miniplate fixation of fractures of the symphyseal and parasymphyseal regions of the mandible. A retrospective review of all mandible fractures treated from July 1, 1999, through July 31, 2011, by one of us (Y.D.) was performed. Intraoral, open rigid fixation of noncomminuted symphyseal and parasymphyseal fractures was performed using a combination of 2 miniplates that were either a 4-hole or a 6-hole miniplate using monocortical screws. The miniplates were 1-mm thick with a 2-mm screw diameter. A total of 218 patients with noncomminuted symphyseal and parasymphyseal mandible fractures were included in this study. Eighteen patients (8.3%) with concurrent panfacial fractures and other indications were left in postoperative maxillomandibular fixation (MMF), whereas 200 patients (91.7%) did not require postoperative MMF. All patients in this series achieved bony union. The following complications were noted: plate exposure, 2.3%; malocclusion, 1.4%; wound infection, 1.4%; and tooth root injury, 0.9%. The use of postoperative antibiotics and either a nonlocking or locking system was not associated with significant differences in the rates of complications. For noncomminuted symphyseal and parasymphyseal mandible fractures, the application of 2 miniplates with monocortical screws offers good surgical outcomes in most patients with minimal complications. The advantages of using miniplates include easy plate adaptability, no need for MMF unless indicated, small screw diameter, and provision of adequate load-sharing rigid fixation for simple, noncomminuted symphyseal and parasymphyseal mandible fractures.

Implant Supported Mandible Over Denture with Four Implants Key Facts

Implant retained over denture (IRO) is a satisfactory treatment modality for edentulous patient with problems with their lower denture. There are good reasons why this treatment should be selected in preferences to using tissue supported dentures. There are certain rules that provide a method to control the mechanical environment, addressing factors effecting implant and prosthesis longevity, including magnitude of forces, resistance of prosthesis against theses forces, and the biology of bone and its ability to respond to loading environments. Materials and methods: Ten edentulous patients were selected for implant retained prosthesis for the mandible, with minimum four implants in parasymphysis region and prosthesis were delivered after period of 3 months. Conclusion: Certain important points needs consideration for successful prosthesis and its longevity.

Mandibular fractures at veer Chandra Singh Garhwali Government Medical Science and Research Institute, Garhwal region, Uttarakhand, India: A retrospective study

Background:Mandibular fractures constitute a substantial proportion of cases of maxillofacial trauma. Demographic data related to mandibular fractures are difficult to evaluate because of many variables associated with the studies. The information is as diverse as the countries and the people who inhabit them.Aim:This is a retrospective study designed to determine the site distribution, associated fracture and causes of mandibular fractures in patients presenting to the trauma centre of Veer Chandra Singh Garhwali Government Medical Science and Research Institute, Uttarakhand, India.Materials and Methods:Records of 121 patients with confirmed mandibular fractures presenting over a three year period (i.e., 1st January 2008 to 31st December 2010). Data obtained from record included age, sex, site of fracture and causes.Results:There were 48/121 (39.6%) males and 73/121 (60.3%) females. The most predominant age group of fracture was found to be 21-30 (53/121-43.8%) followed by 11-20 (25/121-20.6%). In this study history of fall was the most common cause of mandibular fracture (66/121-54.5%), followed by road traffic accidents (45/121-37.1%), fights and assault (08/121-6.6%) and industrial accidents (02/121-1.6%). In our study most of the patients suffered from fracture in the parasymphysis (35/139-25.1%) and angle region (32/139-23.0%) followed by body (30/139-21.5%), condyle (21/139-15.1%), symphysis (19/139-13.7%), and ramus (02/121-1.4%) area.Conclusion:In this study mandibular fractures were more prevalent in females especially during the second and third decade of life. History of fall was the most predominant cause of mandibular fracture. The most frequently affected sites were parasymphysis and angle.

Facial fracture management in northwest Nigeria.

Background:Facial fracture is gradually become a public health problem in our community due to the attendant morbidity and mortality. Hence, the aim of this study was to determine the pattern of facial fracture in Dental and Maxillofacial Surgery Department of Usmanu Danfodiyo University Teaching Hospital. This cross-sectional study was undertaken to provide information regarding gender, age, etiology, and diagnosis of patients with maxillofacial fractures.Materials and Methods:A 1-year review of patients diagnosed and treated for facial fractures in Usmanu Danfodiyo University Teaching Hospital between January 2011 and December 2011. The diagnosis was based on radiographic data and clinical examination. The main analysis outcome measures were etiology, age, gender, site, and treatment. Data were organized and presented by means of descriptive statistics and Pearson's Chi-square test. The level of significance adopted was 5%.Results:A total of 40 patients were treated in this period. Over 95% were male, 81% were caused by road traffic crash (RTC) and 86.4% were in the 21-30 years group. Most patients (52%) had mandibular fractures, and the most common site was the body. Most patients with midfacial fractures had fractures of the zygomaticomaxillary region (36%), while fractures of the parasymphyseal region were more common in the mandible 156 (31%). The most common treatment for jaw fractures was mandibulomaxillary fixation (MMF). Stable zygomatic complex fractures were reduced (elevated) intraorally, and unstable ones were supported by antral packs.Conclusions:This study highlights facial fractures secondary to RTC as a serious public health problem in our environment. Preventive strategies remain the cheapest way to reduce direct and indirect costs of the sequelae of RTC. It also bring to the fore the necessity to shift to open reduction and internal fixation (ORIF) of fractures.

Granular cell ameloblastoma showing desmoplasia

Our case of ameloblastoma had a surprisingly long 25 year history, with abnormally large dimensions, a multilocular diffuse-mixed radiographic picture, and was histopathologically diagnosed as granular cell ameloblastoma with desmoplasia. To the best of our knowledge, this is the first ameloblastoma ever reported, that has shown combined features of granular cells, desmoplasia, ameloblastic follicles, plexiform, and acanthomatous patterns. The nature of granular cells in this type of tumor and the significance of their presence have also been reviewed. From the studies on aameloblastomas to date, it seems that the old belief that granular cell ameblastoma is the most aggressive variant of ameloblastoma is a myth, and in all probability, granular cells are just a transitional or matured phase in the life cycle of ameloblastomas, starting with normal stellate reticulum-like cells, leading to a production of granules and finally leading to degeneration and formation of cystic areas.

Descending necrotizing mediastinitis associated with an infected dentigerous cyst

Descending necrotizing mediastinitis (DNM) is a rare condition in which an infection from the head and neck propagates into the mediastinum. The most common cause of DNM is odontogenic infection. DNM is spread by the fascial planes from the neck into the mediastinum and requires an aggressive surgical drainage through cervical and thoracic approaches. We report on a 67-year-old male patient, who had acute mediastinitis related to an infected dentigerous cyst in the left parasymphyseal region. A multidisciplinary team approach was used to treat the patient. The team consisted of thoracic surgeons, maxillofacial surgeons, and a radiologist. After the drainage of the mediastinum and pleural cavity, the cyst was enucleated. The patient was discharged at the 42nd day of hospitalization. The aim of this article is to present diagnosis, management, and follow-up of an infected dentigerous cyst that caused DNM.

Fratura de mandíbula: estudo epidemiológico de 70 casos

Background: Mandible fractures are most often caused by direct trauma, but occasionally, pathologic fractures may occur due to tumor lesions. The surgical approach is determined by the type and the location of the mandible fracture. This study aimed to evaluate the epidemiological profile of 70 patients who suffered mandible fracture and underwent surgery at Instituto Dr. Jose Frota (Fortaleza, CE) between January 2005 and December 2009. Methods: We analyzed medical records of 70 patients who underwent surgical treatment for mandibular fractures and assessed gender, age, skin color, anatomic site of fracture, etiology, associated fractures, treatment, hospitalization and complications. Results: There was male predominance (90%) among patients, with a mean patient age of 28.25 + 11.04 years. Most patients (80%) were Caucasian and from small towns (68%). The most affected jaw sites, in descending order, were the parasymphysis region, body, and angle. The major cause was traffic accidents (70%), with motorcycle accidents being the most prevalent (55.7%). The main associated facial fractures were maxilla fracture type Le Fort and zygomatic-orbital. Surgical treatment was carried out with rigid internal fixation in most patients (75%). The only complication was infection in one patient. Conclusions: Reduction and fixation of mandibular fractures should occur as accurately and quickly as possible, since malocclusion is an important long-term complication. In our study, we did not observe such a complication; there was only one case of infection. Concurrent with the findings of other studies, there was a prevalence of young adult males among patients, and traffic accidents were the main cause. The fractures were frequently located in the parasymphysis region and were corrected through rigid internal fixation in 75% of cases.

Metaanalysis of Maxillofacial Trauma in the Northern Districts of Kerala: One Year Prospective Study

There is an increased incidence of maxillofacial trauma all over the world. A study was conducted to find out the epidemiological characteristics of maxillofacial trauma in Northern districts of Kerala. All the trauma patients who attended the Department of Oral and Maxillofacial Surgery, Government Dental College, Calicut, Kerala during the period of 2006-2007 was included in the study. The incidence, prevalence, age and sex distribution, seasonal and daily variations and aetiology of maxillofacial trauma were studied. The pattern and demographic distribution of fractures of maxillofacial skeleton also were studied. This study indicates a significant increase in the incidence of maxillofacial trauma in the region. There was a male predominance and the highest incidence was in the age group of 20-40 years. Road traffic accident was the most common aetiological factor causing maxillofacial trauma. More than 30% of trauma cases suffered fracture of maxillofacial skeleton. There was an increased incidence of midface fracture when compared to mandibular fractures in the study. Most common site of mandibular fracture was in the parasymphysis region and in the midface was the zygomatic complex region. The increased incidence of maxillofacial trauma following road traffic accidents noted in this study reveals the need for formulating preventive measures in the state of Kerala. Increasing facilities for the management of maxillofacial trauma at local hospitals and medical colleges is mandatory. Training of the paramedical personnel, health workers and also the public regarding first aid and primary trauma care is also necessary.

Direct and tomographic dimensional analysis of the inter-radicular distance and thickness of the vestibular cortical bone in the parasymphyseal region of adult human mandibles

We calculated the inter-radicular distances between the canine, and first and second premolars, of human mandibles and the thickness of the cortical bone at adjacent sites using computed tomographic (CT) imaging, and assessed the precision of the dimensional assessment made by CT compared with the same measurement made directly with calipers. We examined 100 adult cadaveric dentate human hemimandibles. At the level at which monocortical screws are inserted to place miniplates according to the current technique used to treat mandibular fractures, points A, B, and C referred to the canine, and first and second premolars, and were marked to calculate the level of the CT slice and as the reference for sectioning of the hemimandible. Our findings showed that there was no significant difference in the inter-radicular distance or in the thickness of cortical bone between the sides of the mandible. The vestibular cortical bone was less than 3.0mm thick in 91 of the samples. In 98 of the samples the inter-radicular distance between the canine and the first and second premolars was more than 2mm. There was no significant difference in micrometric precision between the dimensional assessment on CT and direct measurement using a caliper. In the region of the mental foramen the screws have cortical bone less than 3mm thick in which to be anchored. The inter-radicular distance suggests that there is a minimal risk of radicular injury when miniscrews are inserted between the alveolar structures. CT is a reliable tool for measuring the inter-radicular distance and the thickness of mandibular cortical bone.

Mandibular Osteosynthesis: A Comparative Evaluation of Two Different Fixation Systems Using 2.0 mm Titanium Miniplates & 3-D Locking Plates

To compare & evaluate postoperative complications & treatment outcome in mandibular fracture fixation using 2.0mm titanium miniplates & 3-D locking plates. 30 patients were divided randomly into two groups of 15 each (including comminuted & malunited fractures). GROUP A was treated with Open Reduction Internal Fixation (ORIF) using 2.0mm miniplates & GROUP B with 3-D locking plates. A total of five complications were observed in four patients: Implant exposure & infection in miniplate group & postoperative neurosensory deficit, implant failure & implant exposure in 3-D group. For fractures in symphysis & parasymphysis region, severely displaced angle fractures and for comminuted fractures 3-D locking plate could be a better option. In the angle & body region a single miniplate fixed according to Champy's technique is easy to place with less surgical time, less surgical trauma, is more economical & has similar clinical results.

Mandibular Osteosynthesis: A Comparative Evaluation of Two Different Fixation Systems Using 2.0 mm Titanium Miniplates and 3-D Locking Plates

To compare and evaluate postoperative complications and treatment outcome in mandibular fracture fixation using 2.0mm titanium miniplates and 3-D locking plates. Thirty patients were divided randomly into two groups of 15 each (including comminuted and malunited fractures). Group A was treated with open reduction internal fixation using 2.0mm miniplates and group B with 3-D locking plates. A total of five complications were observed in four patients: implant exposure and infection in miniplate group and postoperative neurosensory deficit, implant failure and implant exposure in 3-D group. For fractures in symphysis and parasymphysis region, severely displaced angle fractures and for comminuted fractures 3-D locking plate could be a better option. In the angle and body region a single miniplate fixed according to Champy's technique is easy to place with less surgical time, less surgical trauma, is more economical and has similar clinical results.

Pediatric facial injuries: It′s management

Background:Facial injuries in children always present a challenge in respect of their diagnosis and management. Since these children are of a growing age every care should be taken so that later the overall growth pattern of the facial skeleton in these children is not jeopardized.Purpose:To access the most feasible method for the management of facial injuries in children without hampering the facial growth.Materials and Methods:Sixty child patients with facial trauma were selected randomly for this study. On the basis of examination and investigations a suitable management approach involving rest and observation, open or closed reduction and immobilization, trans-osseous (TO) wiring, mini bone plate fixation, splinting and replantation, elevation and fixation of zygoma, etc. were carried out.Results and Conclusion:In our study fall was the predominant cause for most of the facial injuries in children. There was a 1.09% incidence of facial injuries in children up to 16 years of age amongst the total patients. The age-wise distribution of the fracture amongst groups (I, II and III) was found to be 26.67%, 51.67% and 21.67% respectively. Male to female patient ratio was 3:1. The majority of the cases of facial injuries were seen in Group II patients (6-11 years) i.e. 51.67%. The mandibular fracture was found to be the most common fracture (0.60%) followed by dentoalveolar (0.27%), mandibular + midface (0.07) and midface (0.02%) fractures. Most of the mandibular fractures were found in the parasymphysis region. Simple fracture seems to be commonest in the mandible. Most of the mandibular and midface fractures in children were amenable to conservative therapies except a few which required surgical intervention.

Teeth in the Line of Fracture: To Retain or Remove?

The purpose of this study was to analyze mandibular fracture site, relationship of the fracture line to the periodontium, vitality of teeth, displacement of the fracture segments and their implications, and determine whether to retain or remove the teeth in the fracture line. Fifty patients with 62 fractures were involved in this study. An electric pulp tester was used to measure the pulpal response. The degree of fracture displacement and the relationship of the fracture line to the periodontium were evaluated using panoramic radiographs. Fractures of the parasymphysis region constituted a majority of 60.87% in the gross displacement category. Four of 50 patients showed no response presurgically and minimal response postoperatively on pulp vitality testing. Patients with teeth in the fracture line showing no response on pulp vitality testing should be advised extraction to avoid further complications.

Treatment of Mandibular Fractures via Transoral 2.0-mm Miniplate Fixation With 2 Weeks of Maxillomandibular Fixation: A Retrospective Study

The intraoral approach for placement of fixation plates for treatment of mandibular fracture has several advantages over the extraoral approach, including lower morbidity and avoidance of nerve VII injury. If this method were shown to be effective in contributing to a low percentage of postoperative complications, especially infection, nonunion, and need for plate removal, this would be a method of choice in treatment of such injuries, especially in dark-skinned or keloid-forming patients. This was a retrospective study of 337 fractures of the angle, body, and parasymphyseal regions of the mandible treated at St Barnabas Hospital (Bronx, NY), a level I trauma center, from 2001 to 2006. The percentage of such complications was 1%. This method is very useful in the treatment of these injuries.

Tomographic analysis of the interalveolar space and thickness of the vestibular cortical bone in the parasymphyseal region of adult human mandibles

The aim of this study was to determine by computed tomography (CT) the interalveolar distance on mandible relative to the canine, first and second pre-molar, and the thickness of the cortical bone in the same region. A hundred adult cadaveric dentate human hemi-mandibles were examined. A point (P) above the upper margin of the mental foramen was determined, the height at which monocortical screws are inserted to place miniplate according to the technique to treat mandibular fracture. Then, points A, B and C at the same height as point P, referring to the dental units namely canine, first and second pre-molars were marked to determine the CT cut level to measure cortical bone thickness and the interalveolar distance. The figures showed no statistically significant difference between the sides. The thickness of the vestibular cortical bone was less than 3.0mm in 96% of the samples. In 91% of the samples the interalveolar distance between canine, first and second pre-molars was greater than 2mm, a potentially safe condition to insert 2.0-mm diameter monocortical screws at the study points. The individual actual anatomy of the region where screws are to be inserted above the mental foramen is important to perform the technique safely. We believe that the minimal cortical thickness to obtain sufficient screw anchorage should be studied in order to determine the actually safe shortest screw length. It is important to minimize the risk of tooth root damage or nerve injury and the amount of titanium in the human tissues.

Maxillofacial rehabilitation of a 7-year-old boy with osteosarcoma of the mandible using a free fibula flap and implant-supported prosthesis: A clinical report

This clinical report describes the multidisciplinary approach in the maxillofacial rehabilitation of a 7-year-old boy diagnosed with osteosarcoma of the mandible. Following surgical resection of the left half of the mandible from the angle to the parasymphyseal region, a free osseocutaneous flap from the fibula was used to successfully reconstruct the mandible. Dental implants were subsequently placed, and an implant-supported, removable mandibular resection prosthesis was fabricated. Prosthodontic planning and treatment considerations in a growing child with a reconstructed mandible are discussed.

Retrospective Analysis of Two Hundred Thirty-Five Pediatric Mandibular Fracture Cases

Maxillofacial fractures are encountered less commonly during childhood period due to anatomic, social, cultural, and environmental factors. Although the incidence of all maxillofacial fractures is 1% to 15% among pediatric and adolescent patients, this rate drops to less than 1% in children below 5 years age. Two hundred thirty-five cases (<or=16 age) with mandibular fracture were evaluated retrospectively. Patients records were examined in terms of age, gender, cause of fracture, fracture localization, number of fractures, fracture pattern, accompanying injuries, applied treatment methods, and complications. Mean age of cases was 9.2 years and 165 cases were male, 70 were female. Traffic accidents as the most common etiologic cause in all ages. Falls is the second most common cause which particularly affects children above age of 2 years. All cases had 333 fractures and the most common fracture localization was parasymphysis region (34%). The other most common fracture localizations were as follows: condyle (19%), corpus (13%), dentoalveolar region (12%), angulus (11%), symphysis region (9%), and ramus (2%). There was only a single fracture line in 145 cases, 40 cases had unilateral multiple and 50 cases had bilateral fracture lines. We applied symptomatic (conservative) treatment in 20 (8%) of our cases; fracture fixation with interdental wires or closed reduction methods were employed in 122 patients. Internal fixation with open reduction (OR) was performed on 51 (22%) patients. Both closed and OR techniques were carried out in 30 (13%) patients. Pediatric mandibular fractures, which are seen less frequently compared with those of adults, require a specific and different treatment. Although mostly less invasive methods are preferred, we believe that ORs should be considered when required.

Bone Biopsy of the Parasymphyseal Pubic Bone Region in Athletes with Chronic Groin Injury Demonstrates New Woven Bone Formation Consistent with a Diagnosis of Pubic Bone Stress Injury

Background There is little scientific evidence available regarding the pathologic basis for chronic groin injury in athletes, a known difficult clinical problem. Hypothesis Histological analysis of the superior pubic ramus in athletes with diagnosed chronic groin injury may reveal the nature of the pathologic process. Study Design Case series; Level of evidence, 4. Methods Ten athletes with a diagnosis of chronic groin injury by clinical criteria (at least 6 weeks of pain) and magnetic resonance imaging criteria (unequivocal increase in T2 signal intensity) underwent bone biopsy of the superior pubic ramus. The biopsy site was located in the parasymphyseal region in the area of increased magnetic resonance image signal intensity. Histologic analysis of the specimens was then undertaken. Results Evidence of new woven bone was seen in all biopsy specimens. Signs of old bony injury were seen in 8 of the 10 specimens. There was no evidence of inflammation or osteonecrosis. Conclusion Histologic analysis of bone biopsy specimens taken from the parasymphyseal pubic bone region with magnetic resonance imaging T2-weighted increased signal intensity of athletes diagnosed by clinical and magnetic resonance imaging criteria as having chronic groin injury demonstrates new woven bone formation. This is consistent with the athlete having a bone stress injury that may contribute significantly to athletic groin pain.

A comprehensive classification of mandibular fractures: a preliminary agreement validation study

This study evaluates a comprehensive classification system for mandibular fractures based on imaging analysis. The AO/ASIF scheme, defining three fracture types (A, B, C), three groups within each type (e.g. A1, A2, A3) and three subgroups within each group (e.g. A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest) was used. The mandible is divided into two vertical units (I and V), two lateral horizontal units (II and IV) and one central unit (III) comprising the symphyseal and parasymphyseal region. Type A fractures are non-displaced, type B are displaced and type C are multifragmentary/defect injuries. Groups and subgroups are further defined in the classification system. Two classification sessions using semi-automatic software with 7 and 9 surgeons were performed to evaluate 100 fracture cases in the first session and 50 in the second. Inter-observer reliability and individual rater's accuracy were evaluated by kappa coefficient and latent class analysis, respectively. The analysis of inter-observer agreement for the detailed coding showed kappa coefficients around 0.50 with higher agreement among raters in the vertical units. This system allows standardization of documentation of mandibular fractures, although improvement in the definition of categories and their application is required.