Deepak G. Krishnan

Outcomes of Mandible Fracture Treatment at an Academic Tertiary Hospital: A 5-Year Analysis

PURPOSE To analyze the outcomes of mandible fractures treated using open reduction and internal fixation. PATIENTS AND METHODS We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded. RESULTS Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495). CONCLUSIONS A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.

Internal Carotid Artery Pseudoaneurysm After Le Fort I Osteotomy: Report of a Case and Its Management

In the treatment of maxillofacial deformities, the Le Fort I osteotomy is a widely used and versatile procedure. However, complications associated with this procedure are well described and attest to its inherent dangers. The most serious and life-threatening complications are vascular injuries. As reported in the literature, complications primarily involve injury to branches of the external carotid artery, especially the internal maxillary artery, and numerous accounts of intraoperative hemorrhages and management. Accounts of traumatic aneurysms located on branches of the external carotid also exist, yet appear to be rare occurrences. Most of these aneurysms occur in a delayed manner and are primarily associated with projectile injuries or blunt trauma. This case report describes a unique complication, a vascular injury to the internal carotid artery (ICA) in a patient who underwent a Le Fort I osteotomy as part of a procedure to establish a proper maxillomandibular relationship.

Comparison of Direct Laryngoscopy and Video Laryngoscopy in Intubating a Mannequin: Should Video Laryngoscopy Be Available to Manage Airway Emergencies in the Oral and Maxillofacial Surgery Office?

PURPOSE Video laryngoscopy (VL) is an innovation in tracheal intubation that could be beneficial in an emergency situation. However, the technique could be detrimental if it prolongs intubation performed by an inexperienced physician. The purpose of this study was to compare direct laryngoscopy (DL) with VL skill for oral and maxillofacial surgery (OMS) residents and practitioners to assess the practicality of recommending the inclusion of VL as a component of OMS emergency airway management. MATERIALS AND METHODS To address the research purpose, the authors designed and implemented a randomized crossover study investigating the performance of OMS residents and practitioners to intubate a mannequin using DL versus VL. The predictor variables were the experience level of the participants and their ability to intubate with DL and with VL. The outcome variables were time to view cords, the Cormack-Lehane glottis view achieved, the time to intubate the mannequin, and the total time for performing laryngoscopy and intubation. Comparisons of laryngoscopy and intubation and resident and practitioner experiences were compared using Cox proportional hazards survival analysis. RESULTS Data from 22 OMS residents and 26 practitioners were assessed. The comparison outcomes between DL and VL showed that the time to view cords was shorter for VL, the Cormack-Lehane glottis view was better for VL, the time to intubate was shorter for DL, and the total time between techniques was not statistically different. OMS practitioners showed better times than OMS residents and showed adeptness with VL that was comparable to DL. CONCLUSION The combined findings with OMS residents and practitioners showed comparable total intubating times between DL and VL, which is consistent with what has previously been reported with other medical colleagues.

Incidental discovery of asymptomatic radiolucent lesion of the posterior mandible.

A 20-year-old patient was referred to the outpatient clinic f the dental service at Diyarbakır Military Hospital (Diarbakır, Turkey) in February 2006. He was referred to us y his dentist for the evaluation of a mandibular lytic lesion een on panoramic radiographs. It was well-defined and nilocular (Fig 1). The oral cavity appeared normal upon clinical examinaion. Intraorally, there was evidence of slight expansion of he buccal cortex in the right mandibular region, but the ucosa of the gingival margin appeared to be normal in olor. The absence of the right lower first molar extracted 0 years ago was noted. There was no mobility in any of the teeth, which were eactive to vitality testing, showing no local periodontal isease and no evidence of lymph node enlargement. There ere no palpable thrills. Limitation of mouth opening was ot monitored. Hemogram findings, serum chemistry findngs (calcium and phosphate levels), and the erythrocyte edimentation rate were normal. A computed tomography (CT) assessment of the mandile was performed, and this showed a lytic radiolucent esion measuring 4 3 cm in the right mandibular ramus Fig 2). The lesion had no apparent relation with the teeth

Systematic Assessment of the Patient with Facial Trauma

The systematic assessment of patients with facial injuries is the culmination of wisdom from trials and errors, audits of failures and successes, careful and mindful reflection of current practice, and a willingness to change. Emerging technology has positively impacted the practice of management of facial trauma. A systematic evaluation and physical examination of the trauma victim remain the gold standard and the first step toward effective care.

Controversies in Dentoalveolar and Preprosthetic Surgery

Dentoalveolar surgeries are among the more common procedures performed by oral maxillofacial surgeons. It is only natural that there are several controversies associated with many aspects of this type of surgery. Although good scientific evidence is the basis of most oral maxillofacial procedures, some of what is accepted as common wisdom may not meet strict guidelines of evidence-based practice. This article explores some controversies that are relevant to the current practice of dentoalveolar surgery.

Soft Tissue Trauma in the Temporomandibular Joint Region Associated with Condylar Fractures

The role of soft tissue injury within the temporomandibular joint (TMJ) in mandibular fractures in general and condyle fractures in particular has been often overlooked. With improved MRI and the cumulative information gathered from clinical observation, arthroscopic studies and MRI have given us a new insight into the severity and the natural history of soft tissue damage to the TMJ in trauma. There is emerging evidence suggesting concomitant repair of soft tissue injury may lead to improved long-term functional outcome.

Depth of penetration of methylene blue in mandibular cortical bone

BACKGROUND Surgeons treating keratinizing odontogenic tumors (KOT) and other intrabony lesions frequently use methylene blue as an adjunct in peripheral ostectomy in estimating the depth of bone that has been removed. Depth of methylene blue penetration in cortical bone has not been evaluated. STUDY DESIGN Specimens of mandible harvested from 9 fresh unembalmed cadaveric mandibles were stained with methylene blue. A microcaliper was used to measure total thickness of the cortical specimen along with the amount of dye penetration within the cortical block to the nearest 0.1 mm. RESULTS Average depth of dye penetration was 0.48 mm in the symphysis. Average dye penetration was 0.53 mm in the body. Average depth of penetration of 0.42 mm in the angle. CONCLUSIONS The use of methylene blue as a depth gauge to ensure adequate ostectomy with a single application of the dye may be inadequate to ensure complete removal of lesion from bony wall.

Anesthesia for the Pediatric Oral and Maxillofacial Surgery Patient

Pediatric patients present to the oral and maxillofacial surgeon for surgical services that can be performed safely and efficiently. Children and parents tend to be anxious; achieving cooperation is paramount for successful procedures. Several techniques can be used to alleviate anxiety and provide analgesia and anesthesia. This article outlines the anatomy and physiology of children and the preoperative anesthetic preparation and techniques unique to pediatric anesthesia. It discusses standards in training in pediatric anesthesia and current recommendations for monitoring. Management of children with autism spectrum disorders and attention deficit hyperactivity disorders highlights special considerations in the management of these children.

Postoperative Nausea and Vomiting as a Complication of Maxillofacial Surgery

Postoperative and post-discharge nausea and vomiting are common complications following administration of general anesthesia or sedation for surgery. Postoperative nausea and vomiting (PONV) can severely impact postanesthetic recovery time and time to discharge and contribute to an overall patient dissatisfaction for the experience. The pathophysiology of PONV is clearly understood, and so are the risk factors associated with the complication. Management of the condition is done efficiently when all patients that present for surgery are assessed preoperatively and risk stratified for potential PONV. Consensus guidelines are available and updated frequently to help manage PONV. While management guidelines rely on pharmacologic agents, other strategies can also help prevent PONV and also help manage it effectively.