Opioid Prescribing Can Be Reduced in Oral and Maxillofacial Surgery Practice
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Walter Tatch
Purpose
Pain management is one of the most critical aspects of practice in oral and maxillofacial surgery. The purpose of this study was to measure the change in strong (stronger than codeine 30 mg) opioid use after introducing the standardized protocol (“office protocol”) designed for opioid-free postoperative pain management.
Materials and Methods
This is a retrospective cohort study of patients who had surgical procedures performed at the NorthShore Center for Oral and Facial Surgery (Gurnee, IL). Data of patients who underwent qualified surgical procedures and filled prescriptions for strong opioids before and after introduction of the office protocol were analyzed. The primary predictor variable was introduction of the office protocol. The primary outcome variable was filling of a strong opioid prescription that was correlated to pain control as assessed by patients. Age and gender distributions also were analyzed. Proportions and associated 95% confidence intervals were used to compare the number of hydrocodone or oxycodone (strong) prescriptions filled by patients during a 3-year interval.
Results
In March 2016, the office protocol for pain management, designed to decrease opioid use, was introduced. In 2015 (before introduction of the office protocol), 2,016 adult patients (15 to 85 yr old) underwent qualified surgical procedures at the author's practice, 1,184 (59%) of whom required and filled strong opioid prescriptions. In 2017 (2 yr after introduction of the office procedure) that number decreased to 19%, whereas the number of qualified surgical procedures performed remained relatively the same between the years. Postoperative pain control was not qualitatively measured but was assumed adequate and correlated with the filling of a strong opioid prescription or requiring a refill, which would be recorded as part of total prescriptions filled.
Conclusion
A 3-fold decrease in hydrocodone or oxycodone prescription fill was seen at the 2-year interval. As alternatives, nonsteroidal anti-inflammatory drugs, acetaminophen, and a homeopathic recovery kit (Vega Recovery Kit, StellaLife, Glenview, IL) were used for pain management for patients undergoing various oral surgery procedures.
|
News and Announcements
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s):
|
Outcomes of Zygomatic Complex Reconstruction With Patient-Specific Titanium Mesh Using Computer-Assisted Techniques
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Wen-Bo Zhang, Yao Yu, Chi Mao, Yang Wang, Chuan-Bin Guo, Guang-Yan Yu, Xin Peng
Purpose
Zygomatic complex defects after extensive maxillectomy can cause severe esthetic and functional deformities. Patient-specific titanium mesh fabricated using a computer-assisted technique is a promising method for such midface reconstruction. The aim of this study was to evaluate the application and clinical outcomes of this technique.
Patients and Methods
This was a retrospective study that included 9 patients with zygomatic complex defects after extensive maxillectomy from 2015 through 2017 at the authors' institution. A 3-dimensional stereo model was obtained based on mirror images of the unaffected side to fabricate a patient-specific titanium mesh using computer-assisted design and manufacturing. Titanium mesh was used to restore the contour of the zygomatic complex with free flap reconstruction after tumor resection. Anterolateral thigh flaps were used in 8 cases and a myocutaneous fibula flap was used in 1 case. Symmetry of the zygomatic complex was evaluated by measuring the zygomatic eminence on the postoperative computed tomogram, and complications were recorded during follow-up visits. Facial symmetry was self-evaluated and scored.
Results
Mean duration for follow-up was 27.3 months (range, 15 to 39 months). Mean deviation of the zygomatic eminence between the reconstructed and unaffected sides was 1.4 ± 0.5 mm. No significant difference was noted in the zygomatic eminence between the reconstructed and unaffected sides (P = .591). Titanium mesh exposure occurred in only 1 patient after radiotherapy. There were no other remarkable complications. All patients were satisfied with their postoperative facial symmetry.
Conclusion
Patient-specific titanium mesh fabricated using a computer-assisted technique was an alternative option for extensive zygomatic complex reconstruction, resulting in acceptable clinical outcomes. A study with a larger sample and long-term follow-up is needed for the observation of long-term outcomes and risk of titanium mesh-related complications.
|
Are Comorbidities Associated With Overall Survival in Patients With Oral Squamous Cell Carcinoma?
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Úrsula M. Jariod-Ferrer, Jose M. Arbones-Mainar, Marina A. Gavin-Clavero, M. Victoria Simón-Sanz, Ignacio Moral-Saez, Ana I. Cisneros-Gimeno, Javier Martinez-Trufero
Purpose
Oral squamous cell carcinoma (OSCC) is a highly prevalent type of immunogenic cancer with a low survival rate in patients with comorbidities owing to toxic habits.
Materials and Methods
A retrospective cohort study was conducted of patients with resectable OSCC at a tertiary Spanish hospital from 2011 to 2014. The primary predictor variables were comorbidity and immune biomarkers. Comorbidity was assessed using the Adult Comorbidity Evaluation–27 (ACE-27) and scored from 1 to 3 (mild to severe decompensation, respectively). The immune biomarkers were neutrophil-to-lymphocyte ratio (NLR), derived NLR (dNLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR). The primary outcome variable was 5-year overall survival (OS). Other study variables were stage, margin, and neck management. Receiver operating characteristic curves were built for each ratio. For the survey of immune biomarkers, area under the curve was computed to determine cutoff points and investigate their association with OS. Kaplan-Meier estimates of survival and Cox proportional hazards models were used for longitudinal analysis.
Results
Overall 215 patients were identified (median age, 67 yr; range, 32 to 96 yr; median follow-up, 31 months; range, 7 to 78 months); 159 patients had at least 1 comorbid condition. Results showed that a severe comorbidity (according to the ACE-27) increased the risk of death by 4 times in patients with OSCC regardless of stage. NLR, dNLR, LMR, and PLR were associated with OS in the univariate study. Cutoff points to predict increased mortality were 3, 1.9, 2.6, and 66 for NLR, dNLR, LMR, and PLR, respectively. Age, comorbidity, stage, margins, and management of the neck were important independent predictors of decreased OS in OSCC. PLR was marginally associated with OS in the multivariate model.
Conclusion
These results suggest that comorbidity and NLR, dNLR, LMR, and PLR are associated with 5-year OS in patients with resectable OSCC.
|
Facial Donor Restoration: One-Step Technique
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Hector Hurtado-Ruzza, Paloma Sosa-Fajardo, Benjamin Martin-Biedma, Mario Pérez-Sayáns, Pedro Infante-Cossio, Abel García-García
Purpose
Successful management of facial allotransplantation requires planning and overcoming a long list of obstacles, not least, the restoration of the donor cadaver (DC).
Materials and Methods
We have presented an innovative single-step facial reconstruction technique for the DC using light-curing material to simplify the infrastructure needs and optimize the time and costs associated with traditional facial restoration techniques reported to date. We also developed a study based on the creation of 7 facial masks over a white male formaldehyde-preserved cadaver head to evaluate the production time of the mask, likeness to the original face, temperature, and adaptation of the mask to the defect.
Results
The average time for the adjustment of the light-curing resin sheets over the DC, photopolymerization, and cosmetic adjustment and application over the facial defect was 5, 4, and 16.4 minutes, respectively, for a global average time of 25.4 minutes. In all cases, the likeness to the original was good, and the average temperature over the donor area was 19.8°C. The adaptation of the mask to the facial defect was accurate in all cases.
Conclusions
The presented one-step technique proposed for facial restoration of the DC had a short learning curve, low costs, and accurate and predictable results.
|
Correlation Between Soft and Hard Tissue Changes in the Zygomaticomaxillary Region After Bone Contouring Surgery for Fibrous Dysplasia—A Preliminary Study
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Bimeng Jie, Baocheng Yao, Jingang An, Yi Zhang, Yang He
Purpose
The purpose of the present study was to determine the correlation between the soft and hard tissue changes in the zygomaticomaxillary region after facial bone contouring surgery for patients with craniofacial fibrous dysplasia (FD).
Materials and Methods
The present study was a retrospective case series that reviewed the cases of 13 patients with craniofacial FD in the zygomaticomaxillary region who had undergone navigation-guided facial bone contouring surgery from January 2013 to October 2017. Pre- and postoperative computed tomography (>3 months) were collected. The pre- and postoperative soft and hard tissues were placed in the same spatial coordinate system using multipoint registration to measure the distances between the corresponding pre- and postoperative points of the soft and hard tissues. The outcome variable was the corresponding soft tissue change. The correlation between the hard and soft tissue changes was obtained using correlation analysis with SPSS software (IBM Corp, Armonk, NY). The linear regression equation of the soft and hard tissue changes was used to predict the corresponding soft tissue changes.
Results
The Pearson correlation coefficient of the zygomatic region was 0.954 (P < .001) and the coefficient for the maxillary region was 0.758 (P < .001). The linear regression index (R2) for the zygomatic and maxillary regions was 0.910 (P < .001) and 0.575 (P < .001), respectively. The β value of the linear regression equation for the zygomatic and maxillary regions was 0.815 (P < .001) and 0.52 (P < .001), respectively.
Conclusions
The soft and hard tissue changes were highly correlated in both the zygomatic area and the maxillary area, and the variance of the maxillary area was slightly greater than that in the zygomatic area. This implied that the change of 1 mm of bone tissue along the tangent direction of the bone contour will cause a change of 0.815 mm in the soft tissue in the zygomatic region and 0.52 mm in soft tissue in the maxillary region.
|
Evaluation of Surgical Bur Deformation and Bone Surface Roughness After Multiple Uses
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Mauricio Montero-Aguilar, Laura Sibaja-Ruiz, Esteban Avendaño, Reinaldo Pereira-Reyes, Amaury Pozos-Guillén, Daniel Chavarria-Bolaños
Purpose
The aim of the present in vitro study was to microscopically evaluate and describe the deformation of Lindeman surgical burs and the bone surface roughness after repeated osteotomies and sterilization cycles.
Materials and Methods
Twenty-one Lindeman surgical burs were analyzed under scanning electron microscopy (SEM) to evaluate the damage of the bur's integrity after 0, 1, 3, 5, 7, or 9 osteotomies on bovine ribs. Eighteen bone specimens were obtained after osteotomy for roughness analysis using profilometry. One-way analysis of variance was used to compare the mean roughness values across the experimental groups, and P ≤ .05 was considered to indicate statistical significance.
Results
Representative SEM images illustrated that all analyzed burs presented with some type of deformation at both the tip and the body, even after their first use. The mean roughness values were independent of the number of uses (P > .05); however, the standard deviation increased with the number of uses of the burs.
Conclusions
These results suggest that even after their first use, rotatory surgical burs will have some type of deformation and that their cutting efficiency on the bone will vary and will be difficult to predict.
Graphical abstract
|
Does Mandible-First Sequencing Increase Maxillary Surgical Accuracy in Bimaxillary Procedures?
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Kasper Stokbro, Jeroen Liebregts, Frank Baan, R. Bryan Bell, Thomas Maal, Torben Thygesen, Tong Xi
Purpose
In bimaxillary procedures, it is important to know how the chosen sequence affects the surgical outcome. The purpose of this study was to explore whether the theoretical advantages of using the mandible-first procedure were supported by clinical data.
Materials and Methods
The authors performed a retrospective investigation on a cohort compiled from 3 published retrospective studies. The sample was composed of patients treated at the Radboud University Nijmegen Medical Centre (Nijmegen, the Netherlands) from 2010 to 2014 and the Odense University Hospital (Odense, Denmark) from 2011 to 2015. The inclusion criterion was bimaxillary surgery without maxillary segmentation. The exclusion criterion was lack of a virtual surgical plan. The primary outcome variable was surgical accuracy, defined as the mean difference between the obtained outcome and the virtual surgical plan. The primary predictor variable was the comparison between mandible-first and maxilla-first sequencing. Secondary predictors were inferior maxillary repositioning and counterclockwise (CCW) rotation. The confounding variable was the virtually planned reposition. Results were analyzed by mixed-model regression encompassing all variables, followed by a detailed analysis of positive results using 2-sample ttests.
Results
Overall, 145 patients were included for analysis (98 women; mean age, 28 years). Operating on the mandible first notably influenced maxillary positioning and placed the maxilla 1.5 mm posterior and with 1.4° of CCW rotation compared with virtual surgical planning. The interaction of surgical sequence with maxillary rotation showed similar surgical accuracy between maxilla-first surgery with clockwise rotation and mandible-first surgery with CCW rotation. Inferior maxillary repositioning resulted in the maxilla being placed 1.7 mm (maxilla-first sequence) and 2.0 mm (mandible-first sequence) posterior to the planned position.
Conclusion
Surgical accuracy was considerably influenced by sequencing in bimaxillary procedures. It remains important to know how the chosen sequence affects the surgical outcome so that the virtual surgical plan can be adjusted accordingly.
|
What Are the Characteristics of the Upper Airway in Patients With Craniofacial Microsomia?
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Yoram P. Klazen, Cornelia J.J.M. Caron, Sontje C. Schaal, Alessandro Borghi, Marc P. Van der Schroeff, David J. Dunaway, Bonnie L. Padwa, Maarten J. Koudstaal
Purpose
Obstructive sleep apnea (OSA) is a common problem in patients with craniofacial microsomia (CFM); however, the exact pathophysiology in patients with CFM remains unclear. The first aim of this study was to evaluate upper airway volume and morphology in patients with CFM. The second aim was to identify risk factors for the presence of OSA.
Materials and Methods
A cross-sectional study was set up and 3 study groups were identified: 1) CFM with OSA, 2) CFM without OSA, and 3) control. Computed tomographic (CT) scans of the head and neck were included and used to create 3-dimensional models. The age-matched control group consisted of patients evaluated for traumatic head injury or epilepsy. Volumetric and morphologic parameters were measured. The results of patients with CFM were compared among the 3 study groups. Descriptive statistics were computed using the Pearson χ2 test for categorical variables and nonparametric tests for continuous variables. A multiple variable regression model was used to identify risk factors for OSA.
Results
In total, 79 patients with CFM were included, of which 25 patients were diagnosed with OSA. A total of 145 CT scans could be analyzed. In addition, a control population of 88 patients was identified. Oropharynx volume, mean cross-sectional area (CSA), minimal CSA, and minimal retropalatal area were found to be markedly smaller in patients with CFM compared with the control population. In contrast, in patients with CFM and OSA, minimal retroglossal area, sphericity, and uniformity markedly differed from those in patients without OSA. Sphericity was identified as the main predicting variable of OSA in patients with CFM.
Conclusions
The upper airway of patients with CFM is markedly smaller and puts them at risk for developing OSA. Patients with CFM diagnosed with OSA have a markedly smaller CSA behind the base of the tongue and a difference in sphericity.
|
Biomechanical Evaluation of Mandibular Condyle Fracture Osteosynthesis Using the Rhombic Three-Dimensional Condylar Fracture Plate
Publication date: September 2019
Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 9
Author(s): Anas Ben Achour, Heike Meißner, Uwe Teicher, Dominik Haim, Ursula Range, Alexander Brosius, Henry Leonhardt, Günter Lauer
Purpose
The aim of the present study was to evaluate the biomechanical stability of osteosynthesis in mandibular condyle fractures using a newly designed rhombic 3-dimensional (3D) condylar fracture plate and compare it with that using standard two 4-hole miniplates and with that in nonfractured condyles.
Materials and Methods
Using 200 porcine mandibles, 3 different monocortical plating techniques were evaluated. The condyles were fractured along a defined line tangentially through the sigmoid notch and perpendicular to the posterior border. After anatomic reduction, osteosynthesis was performed using either standard rhombic 3D condylar fracture plates and standard screws (group A) or locking rhombic 3D condylar fracture plates, which were fixed either with standard screws (group B) or locking screws (group C). For comparison, nonfractured condyles (group D) and condyles fixed with standard two 4-hole miniplates and 8 screws (group E) were included. Using a universal mechanical testing machine (TIRA Test 2720; TIRA GmbH Schalkau, Germany), each group was subjected to linear loading from laterally to medially, medially to laterally, anteriorly to posteriorly, and posteriorly to anteriorly. The maximum axial force and displacement at the maximum force were measured. The mean values were compared for statistical significance using analysis of variance with Bonferroni's correction (statistical significance set at P < .05).
Results
The main mode of failure in the plating techniques investigated was the pull out of screws from the proximal fragment. We found no statistically significant differences in the stability of osteosynthesis between the two 4-hole miniplates and the rhombic 3D condylar fracture plate when loading from posteriorly to anteriorly, laterally to medially, and medially to laterally. However, when loading from anteriorly to posteriorly, a statistically significant difference between the standard and locking system and the two 4-hole miniplate system was observed, with the latter proving more stable.
Conclusions
The results of the present biomechanical study suggest that the rhombic 3D condylar fracture plates are suitable for the treatment of condylar neck fractures. Both types of the plate are able to resist physiologic strains comparable to the two 4-hole miniplates.
|
| Anesthesia/TMJ Disorders/Facial Pain |
|
| Craniomaxillofacial Trauma |
|
| Craniomaxillofacial Deformities/Sleep Disorders/Cosmetic Surgery |
|
| Surgical Oncology and Reconstruction |
|
Δεν υπάρχουν σχόλια:
Δημοσίευση σχολίου