Need for Redo Surgery of Maxillofacial Fractures

Abstract

The purpose of the present study was to describe the demographic and clinical features of patients having undergone redo surgery for mandibular and/or midfacial fractures and to identify factors that increase the odds of redo surgery. Included were the files of all patients who had undergone open reduction and fixation of one or more mandibular and/or midfacial fracture or orbital reconstructions at the Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, Helsinki, Finland, between 1 January 2013-31 October 2020. Patients having undergone redo surgery were identified, and descriptive characteristics were calculated. In the data analysis, the association between redo surgery and explanatory variables was analyzed. Altogether, 1176 patients were identified for the analysis. Of these, 25 (2.1%) underwent redo surgery for 28 fracture sites. The most common reasons for redo surgery were inadequate fracture reductions of the zygomatic process or the mandible (19 patients) and inadequate orbital reconstructions (four patients). Compared with surgery of only the mandible, combined surgery of the mandible and midface had almost four times greater odds of redo surgery (95% CI 3.8, 0.8-18.4), but the finding was not statistically significant. Although redo surgery was required fairly infrequently, the findings highlight the relevance of surgical competence to treatment success; suboptimal surgical procedure was the most common reason for redo surgery. The literature supports the use of intraoperative CT scanning as a useful tool in association with the treatment of complex midfacial fractures in general and orbital fractures in particular. The success of orbital reconstruction can be promoted by using patient-specific implants.

Keywords: complications; maxillofacial fractures; redo surgery; revision surgery.

Figure 1

The patient’s left midfacial fractures have been insufficiently reduced. The left malar bone is located inferiorly and rotated laterally, and the medial maxillary and nasal bone fractures are in severe malposition (blue arrows). Although the left orbital floor is reconstructed, the volume of the orbit is increased (red arrows) due to the malposition of the malar bone and the medial maxilla. With the aid of three-dimensional surgical planning and intraoperative CT-scanning, redo surgery could have been avoided in this patient.

Figure 2

(a) The patient suffered from complex midfacial and mandibular fractures as a result of a fall. (b) Reduction of midfacial fractures was insufficient, resulting in an open bite with contacts only between the second molars. The dislocated upper jaw should have been reduced anatomically precisely in all planes of space before the reduction and osteosynthesis of the fracture in the mandible. Moreover, in order to achieve a preinjury occlusion, it is essential to ensure that the mandibular condyles are correctly situated in the glenoid fossae before fixation.

Figure 2

(a) The patient suffered from complex midfacial and mandibular fractures as a result of a fall. (b) Reduction of midfacial fractures was insufficient, resulting in an open bite with contacts only between the second molars. The dislocated upper jaw should have been reduced anatomically precisely in all planes of space before the reduction and osteosynthesis of the fracture in the mandible. Moreover, in order to achieve a preinjury occlusion, it is essential to ensure that the mandibular condyles are correctly situated in the glenoid fossae before fixation.

Figure 3

(a) A fracture of the right mandibular angle was fixed with one plate parallel to the line of force of the mandible. The third molar, exhibiting periodontitis, was left in the line of fracture. The patient suffered from prolonged infection at the surgical site, which eventually resulted in malunion. (b) Malunion was treated by revision and fixation with a reconstruction plate through a cervical approach a little less than three months after primary surgery. The infected teeth were removed. The tooth in the fracture line clearly represented a risk for infection and should have been removed during surgery.

Figure 3

(a) A fracture of the right mandibular angle was fixed with one plate parallel to the line of force of the mandible. The third molar, exhibiting periodontitis, was left in the line of fracture. The patient suffered from prolonged infection at the surgical site, which eventually resulted in malunion. (b) Malunion was treated by revision and fixation with a reconstruction plate through a cervical approach a little less than three months after primary surgery. The infected teeth were removed. The tooth in the fracture line clearly represented a risk for infection and should have been removed during surgery.