Carlos H. Buitrago-Téllez

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 raters 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.

Colonic involvement in non-necrotizing acute pancreatitis: correlation of CT findings with the clinical course of affected patients

Abstract. The purpose of this study was to describe CT findings of colonic involvement in acute non-necrotizing pancreatitis and to analyze the correlation between colonic wall thickening at CT and the clinical course of these patients. The CT examinations of 19 consecutive patients with acute non-necrotizing pancreatitis who were not treated with antibiotics initially were analyzed retrospectively. The severity of acute pancreatitis was categorized according to the CT severity index (CTSI) and the presence of colonic wall thickening at the initial CT was compared with the clinical course of all patients. Seven of 11 patients with a CTSI of 4 showed a colonic wall thickening, whereas the remaining patients with a CTSI of 4 (n=4), CTSI of 3 (n=5), and CTSI of 2 (n=3) showed no colonic abnormalities at CT. Patients with colonic wall thickening presented more often with fever, showed higher levels of infectious parameters, needed more often antibiotic therapy, and had more requests for additional CT examinations and CT-guided fluid aspirations as well as a longer duration of hospital stay as compared with patients without colonic wall involvement, even if the latter presented with the same CTSI initially. It is well known that translocation of the colonic flora may significantly influence the clinical course of patients with acute pancreatitis, and our results indicate that patients with acute pancreatitis who present with colonic wall thickening at CT have an increased risk for a complicated clinical course regarding systemic infection.

The Comprehensive AOCMF Classification System: Midface Fractures - Level 3 Tutorial

This tutorial outlines the details of the AOCMF image-based classification system for fractures of the mandibular arch (i.e. the non-condylar mandible) at the precision level 3. It is the logical expansion of the fracture allocation to topographic mandibular sites outlined in level 2, and is based on three-dimensional (3D) imaging techniques/computed tomography (CT)/cone beam CT). Level 3 allows an anatomical description of the individual conditions of the mandibular arch such as the preinjury dental state and the degree of alveolar atrophy. Trauma sequelae are then addressed: (1) tooth injuries and periodontal trauma, (2) fracture involvement of the alveolar process, (3) the degree of fracture fragmentation in three categories (none, minor, and major), and (4) the presence of bone loss. The grading of fragmentation needs a 3D evaluation of the fracture area, allowing visualization of the outer and inner mandibular cortices. To document these fracture features beyond topography the alphanumeric codes are supplied with distinctive appendices. This level 3 tutorial is accompanied by a brief survey of the peculiarities of the edentulous atrophic mandible. Illustrations and a few case examples serve as instruction and reference to improve the understanding and application of the presented features.

Skull base and maxillofacial fractures : two centre study with correlation of clinical findings with a comprehensive craniofacial classification system

PURPOSE A comprehensive classification based on high resolution computed tomography (CT) of the whole craniofacial region was correlated with clinical findings of combined skull base and maxillofacial fractures. MATERIAL AND METHODS In a study of two clinical centres, 70 patients with such injuries were admitted at the Universities of Basel (n=29) and Uppsala (n=41). Clinical signs (rhinorrhoea, periorbital haematoma and pneumencephalus) and surgical versus conservative treatment were correlated with a cranio-maxillofacial injury severity score (CMF-ISS) calculated from the classification system. Fracture classifications were decided in consensus on the basis of CT and semiautomatic classification software. The classification system defined 3 fracture types (A, B, C), 3 groups (A1, A2, A3), and 3 subgroups (A1.1, A1.2, A1.3) with increasing severity from A1.1 (lowest) to C3.3 (highest). RESULTS Of 70 patients, 43 were operated upon and 27 conservatively treated. The operated patients had significantly higher severity scores than non-operated. Patients with or without periorbital haematoma do not differ significantly in the severity score. The severity of the CMF-ISS score was significantly associated (two sample T-test P<0.01) with the occurrence of pneumencephalus, rhinorrhoea and treatment approach. CONCLUSION Based on our present results, this system seems to be clinical useful for operative decisions and interventions.

Near-real time oculodynamic MRI: a feasibility study for evaluation of diplopia in comparison with clinical testing

AbstractObjectiveTo demonstrate feasibility of near-real-time oculodynamic magnetic resonance imaging (od-MRI) in depicting extraocular muscles and correlate quantitatively the motion degree in comparison with clinical testing in patients with diplopia.MethodsIn 30 od-MRIs eye movements were tracked in the horizontal and sagittal plane using a a TrueFISP sequence with high temporal resolution. Three physicians graded the visibility of extraocular muscles by a qualitative scale. In 12 cases, the maximal monocular excursions in the horizontal and vertical direction of both eyes were measured in od-MRIs and a clinical test and correlated by the Pearson test.ResultsThe medial and lateral rectus muscles were visible in the axial plane in 93% of the cases. The oblique, superior and inferior rectus muscles were overall only in 14% visible. Horizontal (p = 0,015) and vertical (p = 0,029) movements of the right eye and vertical movement of the left eye (p = 0,026) measured by od-MRI correlated positively to the clinical measurements.ConclusionsOd-MRI is a feasible technique. Visualization of the horizontal/vertical rectus muscles is better than for the superior/inferior oblique muscle. Od-MRI correlates well with clinical testing and may reproduce the extent of eye bulb motility and extraocular muscle structural or functional deteriorations. Key Points• Oculodynamic MRI technique helps clinicians to assess eye bulb motility disorders• MRI evaluation of eye movement provides functional information in cases of diplopia• Oculodynamic MRI reproduces excursion of extraocular muscles with good correlation with clinical testing• Dynamic MRI sequence supplements static orbital protocol for evaluation of motility disorders

Globe restriction in a severely myopic patient visualized through oculodynamic magnetic resonance imaging (od-MRI)

Different mechanisms have been hypothesized as contributing to abduction deficit in high myopia: the size of the eye within the orbit, tightness of the medial rectus muscles, decompensation of longstanding esotropia, and inferior displacement of the lateral rectus muscle. Using oculodynamic magnetic resonance imaging, enhanced by computer-aided visualization, we demonstrate globe restriction by the medial orbital wall on abduction in a patient with high myopia.

The Comprehensive AOCMF Classification System: Radiological Issues and Systematic Approach

The AOCMF Classification Group developed a hierarchical three-level craniomaxillofacial (CMF) classification system with increasing level of complexity and details. The basic level 1 system differentiates fracture location in the mandible (code 91), midface (code 92), skull base (code 93), and cranial vault (code 94); the levels 2 and 3 focus on defining fracture location and morphology within more detailed regions and subregions. Correct imaging acquisition, systematic analysis, and interpretation according to the anatomic and surgical relevant structures in the CMF regions are essential for an accurate, reproducible, and comprehensive diagnosis of CMF fractures using that system. Basic principles for radiographic diagnosis are based on conventional plain films, multidetector computed tomography, and magnetic resonance imaging. In this tutorial, the radiological issues according to each level of the classification are described.

Rare complication after Le Fort I osteotomy

Malfunctions of the eustachian tube after Le Fort I osteotomies are rare. A 22-year-old woman was treated by Le Fort I osteotomy for maxillary retrognathism. Postoperatively she developed recurrent tubal malfunction and middle ear effusions on the left side, with no improvement after adenotomy, tonsillectomy, and grommet insertion. In consecutive computed tomography and magnetic resonance imaging scans, a forward dislocation of the left pterygoid hamulus was demonstrated. In addition, damage to the tensor veli palatini muscle was evident. Both postoperative sequelae appear to be responsible for the unilateral tubal dysfunction.

A computer-based comparative quantitative analysis of surgical outcome of mandibular reconstructions with free fibula microvascular flaps

Abstract The free fibula osteoseptocutaneous flap is the standard for reconstruction of extensive mandibular defects. The procedure must be precise to achieve the required functional and aesthetic results. The aim of the present study was to calculate retrospectively the exact differences in surgical outcome based on preoperative and postoperative Computed Tomography data sets. Ten patients with unilateral reconstructions of the mandible with a fibula based on conventional planning were analyzed quantitatively, applying mirroring techniques with direct comparison of the theoretically optimum with the actual reconstruction. The results showed that there is a significant discrepancy between what is actually achieved and the theoretical optimum. The result of the present retrospective analysis shows that there is room for further improvement of the outcome in complex mandible reconstruction cases.

Eine seltene Komplikation nach Le-Fort-I-Osteotomie

Malfunctions of the eustachian tube after Le Fort I osteotomies are rare. A 22-year-old woman was treated by Le Fort I osteotomy for maxillary retrognathism. Postoperatively she developed recurrent tubal malfunction and middle ear effusions on the left side, with no improvement after adenotomy, tonsillectomy, and grommet insertion. In consecutive computed tomography and magnetic resonance imaging scans, a forward dislocation of the left pterygoid hamulus was demonstrated. In addition, damage to the tensor veli palatini muscle was evident. Both postoperative sequelae appear to be responsible for the unilateral tubal dysfunction.