Abstract
The purpose of the present study was to investigate the necessity of routine postoperative radiographic analysis in patients with maxillofacial trauma. Between January 2000 and January 2010, 579 patients were treated surgically for 646 maxillofacial fractures including complex maxillofacial trauma. The incidence of surgical retreatments based on postoperative radiographs after maxillofacial trauma were investigated. 16 patients needed surgical retreatment. The decision to revise was based on postoperative imaging alone in one patient (0.2%). The available data in the literature concerning postoperative radiography in maxillofacial trauma was reviewed. Six useful studies concerning postoperative radiography in maxillofacial trauma were available for review. When combining these studies a total of 1377 patients underwent surgery for correction of a maxillofacial fracture. Nine patients returned to the operating theatre for correction of the initial procedure after trauma (0.7%). The present results are in line with the available literature. Routine postoperative radiography is not necessary after surgical treatment of maxillofacial trauma. Avoiding routine postoperative radiography will lead to a reduction in exposure of patients to ionizing radiation, a reduction of costs and probably a more efficient discharge.
Radiographs are taken routinely after surgical treatment for maxillofacial fractures . Several reasons are given to justify postoperative radiographic analysis, including evaluation of surgical treatment, detection of defects after surgery before the patient is discharged, registration of the osteosynthesis material for possible removal in the future, and for teaching and judicial reasons , but there is little evidence for this justification .
The Royal College of Radiologists suggested that unnecessary radiation from diagnostic radiology causes 100–250 deaths from cancer every year worldwide . Although it is stated that the risk from radiography is low, M emon et al. found a significant association between dental X-ray exposure and the risk of thyroid cancer . In this study, the dose of radiation exposure or other previous radiographic examinations (CT or other medical X-ray investigations) were not investigated. Other authors have stated that there is a possible association between the use of diagnostic radiography and the development of tumours in the brain and parotid gland . In contrast, R odvall et al. did not find clear evidence associating radiographs with brain tumours . R on commented that it is difficult to study the radiation-associated cancer risk, because the doses of radiation for diagnostic examination are low and epidemiological methods are not easily applicable . In conclusion, the relationship between maxillofacial radiographic analysis and elevated cancer risk is debatable. According to the ALARA (as low as reasonably achievable) principle, unnecessary radiography should be minimized.
The management of facial fractures has changed in recent years from closed reduction and fixation to mainly open reduction with fixation. The benefit of postoperative radiographic quality analysis is therefore questionable as fracture lines can be judged directly during surgery and therefore postoperative radiographs will not supply more information . Another questionable aspect of taking postoperative radiographs is described by D urham et al. They demonstrated that only 57% of the radiographs were reviewed by a member of staff, indicating that 43% of patients were discharged from hospital without the radiographic analysis being reviewed. In the authors’ institute, the protocol is that a radiograph should be reviewed prior to discharge.
Some studies have stated that for postoperative evaluation of maxillofacial fractures, clinical judgement alone is adequate and taking radiographs is unnecessary . The question remains whether the amount of radiation the patient is exposed to, the extra expense and the possible delay in discharge with radiography can be justified. It is not clear if postoperative radiographs influence the decision to return the patient to the operating theatre for a second correction after initial treatment . To clarify this important subject the authors investigated the incidence of surgical retreatments in their institute.
Materials and methods
All patients presenting from January 2000 to January 2010 with maxillofacial trauma were identified. The inclusion criteria were: patients of both sexes with all types of maxillofacial fractures that were treated surgically by open and closed reduction. Patients with dentoalveolar and nose fractures were excluded. The hospital and outpatient records were reviewed and analysed retrospectively. Data collected are gender, age at presentation, type of maxillofacial trauma, type and amount of postoperative analysis taken, open or closed reduction, surgical retreatment and cause of retreatment. Removing the osteosynthesis material and correction of scars were not considered as retreatment of the fracture.
The maxillofacial fractures were subdivided into zygomatic fractures (zygomatic complex or fracture of the zygomatic arch), mandibular fractures (mandibular condyle, mandibular angle, mandible corpus, symphyseal/parasymphyseal fractures), blow-out fractures, Le Fort I/II/III fractures and fracture of the frontal sinus. Type of postoperative analysis included dental panoramic tomography, submentovertex radiograph, occipitomental radiograph, Towne’s view, cephalometric radiograph, posteroanterior radiograph and (cone-beam) CT scan. These analyses were performed immediately postoperatively prior to discharge.
Results
579 patients were surgically treated for 646 maxillofacial fractures. Table 1 gives an overview of the types of fracture. Preoperatively, 1263 radiographic analyses were performed; 1097 radiographs were taken after surgical treatment.
| Type of fracture | No. |
|---|---|
| Fracture of the mandible | 270 |
| Fracture of the zygomatic complex | 243 |
| Fracture of the zygomatic arch | 23 |
| Le Fort I | 19 |
| Le Fort II | 14 |
| Le Fort III | 7 |
| Panfacial fracture | 37 |
| Fracture of the frontal sinus | 18 |
| Blow-out fracture | 15 |
| Total | 646 |
16 patients (3%) needed a secondary treatment ( Table 2 ). Three patients were retreated during their hospital stay (0.5%). In one patient, the zygomatic bone was still clinically dislocated after initial treatment for a complex panfacial trauma. The second patient was treated for a solitary zygomatic complex fracture. After an open reduction with fixation the clinical analysis demonstrated a dislocated complex, retreatment was therefore needed.
| Patient | Time of retreatment | Type of fracture | Cause of retreatment | Retreatment | Decision based on |
|---|---|---|---|---|---|
| 1 | Before discharge | Panfacial trauma | Poor reposition zygomatic complex | Reposition and fixation | Clinical signs |
| 2 | Before discharge | Zygomatic complex | Poor reposition and fixation | Reposition and fixation | Clinical signs |
| 3 | Before discharge | Zygomatic arch | Poor closed reduction | Elevation | Radiographics |
| 4 | Within 2 weeks | Mandible | Malocclusion | Reposition and fixation | Clinical signs |
| 5 | Within 2 weeks | Mandible | Malocclusion | Reposition and fixation | Clinical signs |
| 6 | Within 2 weeks | Mandible | Malocclusion | Reposition and fixation | Clinical signs |
| 7 | Within 2 weeks | Zygomatic complex | Poor closed reduction | Reposition and fixation | Clinical signs |
| 8 | Within 4 weeks | Zygomatic complex | Diplopia and enophthalmia | Secondary reconstruction of the orbital floor | Clinical signs |
| 9 | Within 4 weeks | Zygomatic complex | Diplopia and enophthalmia | Secondary reconstruction of the orbital floor | Clinical signs |
| 10 | Within 4 weeks | Zygomatic complex | Diplopia and enophthalmia | Secondary reconstruction of the orbital floor | Clinical signs |
| 11 | Within 4 weeks | Panfacial trauma | Malocclusion | Reposition and fixation | Clinical signs |
| 12 | After 4 weeks | Mandible | Malocclusion | Unilateral sagittal split osteotomy | Clinical signs |
| 13 | After 4 weeks | Pure blow-out | Diplopia | Shortening orbital floor transplant | Clinical signs |
| 14 | After 4 weeks | Pure blow-out | Enophthalmia | Changing position transplant | Clinical signs |
| 15 | After 4 weeks | Zygomatic complex | Diplopia and enophthalmia | Secondary reconstruction of the orbital floor | Clinical signs |
| 16 | After 4 weeks | Frontal sinus | Malpositioned frontal sinus wall | Reshaping of the frontal sinus | Clinical signs |
The third patient presented with a dislocated zygomatic arch fracture. After closed reduction the radiographic analysis demonstrated a suboptimally performed reposition. The patient underwent surgical retreatment. For these three patients the clinically observed malpositions were confirmed by the postoperative radiographs.
Four patients (0.7%) were retreated surgically within 2 weeks after discharge. All patients were treated as a result of clinical signs. Three of these four patients had a fracture of the mandible and during visits at the out-patient clinic malocclusion was noted. One patient was treated for a fracture of the zygomatic bone by closed reduction. One week after discharge he presented with clinical signs of a dislocated zygomatic complex. Retreatment was necessary. Retrospectively the postoperative radiographs taken prior to discharge showed no malposition or an indication for retreatment.
Another 4 patients (0.7%) were retreated surgically between 2 and 4 weeks after discharge. Three patients needed a secondary correction of the orbital floor after having a fracture of the zygomatic complex. The orbital floor was initially not treated during the reposition of the zygomatic bone, as these patients initially did not show clinical signs which could justify a primary orbital bone reconstruction. The postoperative radiographs performed were simple plain views (submentovertex radiographs and occipitomental radiographs) and on these views no malposition was detectable. The fourth patient was retreated for a developed malocclusion after a complex panfacial trauma. When viewing the postoperative CT scan of this patient the reposition of this panfacial trauma was judged as non-satisfactory.
Five patients (0.9%) were retreated more than 4 weeks after discharge. One patient underwent a unilateral sagittal split osteotomy for correction of a malocclusion after a mandibular fracture. Retrospectively no indication of incorrect reposition could be detected on the postoperative views of this patient. Three patients underwent a secondary correction of the orbital floor (two blow-out fractures and one fracture of the zygomatic complex). These patients initially had no clinical signs but developed enophthalmia and/or diplopia later on. A suboptimal reconstruction of the orbital floor could be detected on the postoperative CT scan of one patient. On the postoperative views of the other two patients no malposition was visible. The fifth patient was retreated for a malpositioned frontal sinus wall after a fracture of the frontal sinus. Retrospectively the postoperative view of this patient showed no indication that something was potentially incorrect. These five retreatments were based on clinical findings only. The radiographic analyses were used to confirm the clinical findings.
Of 25 patients who were treated for reconstruction of the orbital floor 7 patients needed a secondary reconstruction. 18 patients underwent primary reconstruction of the orbital floor. Simple plain views (submentovertex radiographs and occipitomental radiographs) were taken postoperatively in 8 patients. On these views no malposition of the reconstruction could be detected. Postoperative CT-scans were made for eight other patients of whom a suboptimal reconstruction of the orbital floor was seen in one patient but this did not result in clinical problems. The remaining 7 patients showed a satisfactory result of the reconstruction. Data is missing for analysis in two patients.
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