- Email: [email protected]
Poster 107: Outcomes of Mandible Fracture Repair: A 5-year Analysis at a Tertiary Center
Poster Session tures caused by high velocity injuries for cervical spine injuries. References: Haug RH, Wible RT, Likavec MJ, Conforti PJ: Cervical spine fractures and maxillofacial trauma. J Oral Maxillofac Surg 1991;49:725. Mulligan RP, Mahabir RC: The prevalence of cervical spine injury, head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Reconstr Surg;126:1647.
POSTER 106 Development of Anthropometric Titanium Skull for Use in Severe Maxillofacial Trauma Reconstruction B. DeLong: Vanderbilt Medical Center, S. Press Severe maxillofacial trauma presents a daunting task for both the novice and experienced surgeon. Maxillofacial trauma such as pan-facial injuries, where standard landmarks have been lost, make it difficult to return the maxillofacial skeleton to its pre-existing form. In the age of virtual surgical planning and stereolithography, piecing the facial skeletal back together has become more streamlined and mainstream. However, most practicing OMSs have neither the access nor the funding to this cutting edge, expensive technology and therefore could benefit from a reliable, reusable and affordable technology to aid in severe maxillofacial trauma. We have developed an anthropometrically normal titanium skull to accomplish just this. A combination of Steiner and COGS analyses were used to develop a set of normative values and measurements on both cephalometric and AP radiographs of a late-twenties white male. From there, DICOM data from a 0.4 mm slice computed tomography (CT) scan of the maxillofacial skeleton was obtained and a three-dimensional (3D) electronic model of the facial skeleton was reconstructed by Medical Modeling. This image was used in an interactive planning conference with Medical Modeling engineers to finalize skull dimensions, morphology and design based on established normative values. The digital skull was then transformed into a titanium copy using rapid prototyping with laser sintering technology. The anthropometrically normal titanium skull was used in 10 severe maxillofacial trauma cases with excellent postoperative results. All patients had satisfactory reconstruction of their respective maxillofacial defects. In each case, a postoperative CT was obtained and error analysis was completed showing excellent correlation when the preoperative unaffected side was mirrored to overlay the affected side. Subjectively, facial form and symmetry were successfully restored to an acceptable degree. Use of an anthropometrically normal titanium skull is AAOMS • 2012
an excellent surgical adjunct in the primary management of severe maxillofacial trauma. We have used the skull in cases of pan-facial injuries in addition to severe fractures of the frontal sinus, orbit, ZMC, and edentulous mandible. Using the titanium skull as a template for plate bending also resulted in less manipulation of plates and therefore a biomechanically stronger fixation. In many cases a postoperative CT was obtained, revealing excellent bony reduction and symmetry. Titanium was chosen as the material due to its thermal stability, with repeat sterilization, and its compatibility with bending titanium fixation plates. While Virtual Surgical Planning (VSP) has been shown to decrease operating room costs, the disadvantages include increased operating cost and lengthened hospital stay, as transfer of DICOM data, segmentation, virtual reconstruction, Stereolithic model production and shipping take a minimum of 5 days on average, whereas the use of a fabricated titanium skull allows for immediate treatment. Immediate treatment can provide decreased healthcare costs as patients can achieve stepdown status and possibly transfer to a rehabilitation facility more quickly. References: Chang El, et al. Cephalometric Analysis for Microvascular Head and Neck Reconstruction. Head and Neck. 2012 Jan 31. doi: 10.1002/ hed.21967. Holmes S, et al. Evaluation of complex craniomaxillofacial fractures by a new three-dimensional planning system. British Journal of Oral Maxillofacial Surgery. 2006 Oct; 44 (5): 416-417. Epub 2005 Oct 18.
POSTER 107 Outcomes of Mandible Fracture Repair: A 5-year Analysis at a Tertiary Center C. Johnson: University of Cincinnati, K. Tracy The rate of complications following repair of mandibular fractures varies broadly in the literature. The purpose of this study was to evaluate the outcomes of mandible fracture repair at a major academic tertiary care hospital. A retrospective chart review was conducted from January 2006 to December 2011. All patients that had undergone mandible fracture repair, by internal fixation, during that period were included in the study with a minimal follow-up of one month. Pediatric mandible fractures (less than 14 years of age) and charts with incomplete data were excluded from the study. Outcome variables included age, gender, pertinent medical history, smoking, type of fracture, location of fracture, mode of injury, method of fixation, other injuries, use of antibiotics, complications, and follow-up. A total of 560 patients were identified with 364 charts having sufficient data and follow-up. The remaining patients did not follow-up after their surgery or injury. A e-107
Poster Session majority of the patients are White (60%). Males were overwhelmingly affected. Only 7% of the patients had a pertinent medical history. Seventy five percent of the patient’s in this study reported themselves as smokers. Over 80% of the patients were injured by assault, followed by falls and MVC. Sixty percent (186) of the patients had more than one mandible fracture. The most common sites involved in multiple fractured mandibles, were the body and angle region followed by the body and condyle regions. Among isolated fractures, the angle was more frequently involved than other regions; the condyle and body regions were affected equally. Less than 10% of the patients had other concomitant injuries involving other regions of the body. Teeth were identified in the line of fracture in 131 patients (44%). Hardware failure (17%) and wound dehiscence (18%) were the most common complications, followed by wound infections (17%). About 20% of the patients required a second visit to the operating room, to manage the complications. The angle and body were the most common sites of complications. Malocclusion (8%) and nonunion/fibrous union (7%) are relatively low. A majority of the patients did not have financial means to pay for the treatment costs. Multiple site involvement appears to be more common in this group than previously reported. Negative outcomes following the repair of mandible fractures appear to be higher than found in other studies. Follow-up and compliance appear to be the major issues leading to complications. Better treatment strategies need to be developed to manage mandible fractures to avoid negative outcomes that could place a significant burden on the economy. References: Bormann KH, Wild S, Gellrich NC, et al. Five-year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and complications. J Oral Maxillofac Surg. 2009 Jun;67(6): 1251-5. Regev, E., Shiff, J.S., Kiss, A, et al. Internal fixation of mandibular angle fractures: A meta-analysis. Plastic and Reconstructive Surgery, 2010: 125 (6), pp. 1753-1760.
POSTER 108 Clinical Documentation Quality- Can Our Notes Be Used for Outcomes Research? M. E. Engelstad: Oregon Health & Science University, G. Melton, A. Rau Clinical notes are usually written in unstructured narrative formats. Researchers rely on this unstructured documentation for surgical outcomes research. We assessed the documentation quality of clinic encounters following treatment of mandibular fracture - a common injury with known functional and clinical outcomes. We e-108
asked the question, “Will current documentation practices support future outcomes research?” Data Source: 54 paper-based medical records from patients with primary diagnosis ⫽ mandible fracture and at least one postoperative encounter. Site: Dental School-based OMS residency training program. Abstraction: Paper charts were de-identified, scanned to PDF, then abstracted and rated by two authors (AR/ME). A standardized rating method was developed because none existed (Figure 1). 10 separate records were used for initial reviewer calibration and establishment of inter-rater reliability. Scoring: The quality of documentation of basic clinical outcomes was scored in the categories of wound healing, bone union, sensory nerve, motor nerve, facial morphology, occlusion, scar, range of motion, pain, and function. For each record in each category, outcome documentation was given a quality rating (0 – 4). 0⫽ undocumented, 1⫽ subjective report only, 2⫽ ambiguous documentation, 3⫽ explicit documentation, 4⫽ documented by validated method. When unsure, a higher score was assigned. The quality of all post-op documentation was rated as a whole. For instance, if sensory nerve function was documented at only one of three postoperative encounters, that record would still receive a score of 3 for sensory. Statistics: Descriptive statistics were generated, including Cohen’s Kappa () for inter-rater reliability. Conclusions: ¥ Significant variability exists in the consistency and quality of documentation of mandible fracture outcomes. ¥ Few clinical categories are regularly documented in a structured format that is useful for outcomes-based research. ¥ Future surgical outcomes research will require development of structured terminologies and documentation standards. AAOMS • 2012
POSTER 106 Development of Anthropometric Titanium Skull for Use in Severe Maxillofacial Trauma Reconstruction B. DeLong: Vanderbilt Medical Center, S. Press Severe maxillofacial trauma presents a daunting task for both the novice and experienced surgeon. Maxillofacial trauma such as pan-facial injuries, where standard landmarks have been lost, make it difficult to return the maxillofacial skeleton to its pre-existing form. In the age of virtual surgical planning and stereolithography, piecing the facial skeletal back together has become more streamlined and mainstream. However, most practicing OMSs have neither the access nor the funding to this cutting edge, expensive technology and therefore could benefit from a reliable, reusable and affordable technology to aid in severe maxillofacial trauma. We have developed an anthropometrically normal titanium skull to accomplish just this. A combination of Steiner and COGS analyses were used to develop a set of normative values and measurements on both cephalometric and AP radiographs of a late-twenties white male. From there, DICOM data from a 0.4 mm slice computed tomography (CT) scan of the maxillofacial skeleton was obtained and a three-dimensional (3D) electronic model of the facial skeleton was reconstructed by Medical Modeling. This image was used in an interactive planning conference with Medical Modeling engineers to finalize skull dimensions, morphology and design based on established normative values. The digital skull was then transformed into a titanium copy using rapid prototyping with laser sintering technology. The anthropometrically normal titanium skull was used in 10 severe maxillofacial trauma cases with excellent postoperative results. All patients had satisfactory reconstruction of their respective maxillofacial defects. In each case, a postoperative CT was obtained and error analysis was completed showing excellent correlation when the preoperative unaffected side was mirrored to overlay the affected side. Subjectively, facial form and symmetry were successfully restored to an acceptable degree. Use of an anthropometrically normal titanium skull is AAOMS • 2012
an excellent surgical adjunct in the primary management of severe maxillofacial trauma. We have used the skull in cases of pan-facial injuries in addition to severe fractures of the frontal sinus, orbit, ZMC, and edentulous mandible. Using the titanium skull as a template for plate bending also resulted in less manipulation of plates and therefore a biomechanically stronger fixation. In many cases a postoperative CT was obtained, revealing excellent bony reduction and symmetry. Titanium was chosen as the material due to its thermal stability, with repeat sterilization, and its compatibility with bending titanium fixation plates. While Virtual Surgical Planning (VSP) has been shown to decrease operating room costs, the disadvantages include increased operating cost and lengthened hospital stay, as transfer of DICOM data, segmentation, virtual reconstruction, Stereolithic model production and shipping take a minimum of 5 days on average, whereas the use of a fabricated titanium skull allows for immediate treatment. Immediate treatment can provide decreased healthcare costs as patients can achieve stepdown status and possibly transfer to a rehabilitation facility more quickly. References: Chang El, et al. Cephalometric Analysis for Microvascular Head and Neck Reconstruction. Head and Neck. 2012 Jan 31. doi: 10.1002/ hed.21967. Holmes S, et al. Evaluation of complex craniomaxillofacial fractures by a new three-dimensional planning system. British Journal of Oral Maxillofacial Surgery. 2006 Oct; 44 (5): 416-417. Epub 2005 Oct 18.
POSTER 107 Outcomes of Mandible Fracture Repair: A 5-year Analysis at a Tertiary Center C. Johnson: University of Cincinnati, K. Tracy The rate of complications following repair of mandibular fractures varies broadly in the literature. The purpose of this study was to evaluate the outcomes of mandible fracture repair at a major academic tertiary care hospital. A retrospective chart review was conducted from January 2006 to December 2011. All patients that had undergone mandible fracture repair, by internal fixation, during that period were included in the study with a minimal follow-up of one month. Pediatric mandible fractures (less than 14 years of age) and charts with incomplete data were excluded from the study. Outcome variables included age, gender, pertinent medical history, smoking, type of fracture, location of fracture, mode of injury, method of fixation, other injuries, use of antibiotics, complications, and follow-up. A total of 560 patients were identified with 364 charts having sufficient data and follow-up. The remaining patients did not follow-up after their surgery or injury. A e-107
Poster Session majority of the patients are White (60%). Males were overwhelmingly affected. Only 7% of the patients had a pertinent medical history. Seventy five percent of the patient’s in this study reported themselves as smokers. Over 80% of the patients were injured by assault, followed by falls and MVC. Sixty percent (186) of the patients had more than one mandible fracture. The most common sites involved in multiple fractured mandibles, were the body and angle region followed by the body and condyle regions. Among isolated fractures, the angle was more frequently involved than other regions; the condyle and body regions were affected equally. Less than 10% of the patients had other concomitant injuries involving other regions of the body. Teeth were identified in the line of fracture in 131 patients (44%). Hardware failure (17%) and wound dehiscence (18%) were the most common complications, followed by wound infections (17%). About 20% of the patients required a second visit to the operating room, to manage the complications. The angle and body were the most common sites of complications. Malocclusion (8%) and nonunion/fibrous union (7%) are relatively low. A majority of the patients did not have financial means to pay for the treatment costs. Multiple site involvement appears to be more common in this group than previously reported. Negative outcomes following the repair of mandible fractures appear to be higher than found in other studies. Follow-up and compliance appear to be the major issues leading to complications. Better treatment strategies need to be developed to manage mandible fractures to avoid negative outcomes that could place a significant burden on the economy. References: Bormann KH, Wild S, Gellrich NC, et al. Five-year retrospective study of mandibular fractures in Freiburg, Germany: incidence, etiology, treatment, and complications. J Oral Maxillofac Surg. 2009 Jun;67(6): 1251-5. Regev, E., Shiff, J.S., Kiss, A, et al. Internal fixation of mandibular angle fractures: A meta-analysis. Plastic and Reconstructive Surgery, 2010: 125 (6), pp. 1753-1760.
POSTER 108 Clinical Documentation Quality- Can Our Notes Be Used for Outcomes Research? M. E. Engelstad: Oregon Health & Science University, G. Melton, A. Rau Clinical notes are usually written in unstructured narrative formats. Researchers rely on this unstructured documentation for surgical outcomes research. We assessed the documentation quality of clinic encounters following treatment of mandibular fracture - a common injury with known functional and clinical outcomes. We e-108
asked the question, “Will current documentation practices support future outcomes research?” Data Source: 54 paper-based medical records from patients with primary diagnosis ⫽ mandible fracture and at least one postoperative encounter. Site: Dental School-based OMS residency training program. Abstraction: Paper charts were de-identified, scanned to PDF, then abstracted and rated by two authors (AR/ME). A standardized rating method was developed because none existed (Figure 1). 10 separate records were used for initial reviewer calibration and establishment of inter-rater reliability. Scoring: The quality of documentation of basic clinical outcomes was scored in the categories of wound healing, bone union, sensory nerve, motor nerve, facial morphology, occlusion, scar, range of motion, pain, and function. For each record in each category, outcome documentation was given a quality rating (0 – 4). 0⫽ undocumented, 1⫽ subjective report only, 2⫽ ambiguous documentation, 3⫽ explicit documentation, 4⫽ documented by validated method. When unsure, a higher score was assigned. The quality of all post-op documentation was rated as a whole. For instance, if sensory nerve function was documented at only one of three postoperative encounters, that record would still receive a score of 3 for sensory. Statistics: Descriptive statistics were generated, including Cohen’s Kappa () for inter-rater reliability. Conclusions: ¥ Significant variability exists in the consistency and quality of documentation of mandible fracture outcomes. ¥ Few clinical categories are regularly documented in a structured format that is useful for outcomes-based research. ¥ Future surgical outcomes research will require development of structured terminologies and documentation standards. AAOMS • 2012