Perioperative surgical options and medications in mandibular fracture patients

Background and purpose: Postoperative complications are common after mandibular fracture surgery. Antibiotics as well as glucocorticoids like dexamethasone (DXM) are typically used as part of surgical treatment of these fractures. Nonetheless, antibiotic use and surgical protocols for infected mandibular fractures tend to vary significantly between surgeons. The aim of this study was to evaluate medications and perioperative technical aspects to prevent postoperative complications in patients with fractures in the dentate part of the mandible. Additionally, patient-related factors predisposing to complications were evaluated. Patients and methods: This study comprises three retrospective studies (I – III) and one prospective study (IV). Study I comprised patients who had undergone intraoral surgery for a single fracture of the dentate part of the mandible (n=107). The primary outcome variable was postoperative surgical site infection (SSI) and the primary predictor variable was duration of postoperative antibiotic treatment. Study II included patients with an infected fracture of the mandible without preceding surgery (n=41). The primary outcome variable was postoperative surgical site complication. Patient-, fracture-, and surgery-related variables were investigated and predictors for postoperative complications were analysed. Study III comprised patients with one or two fractures of the dentate part of the mandible treated surgically via an intraoral approach (n=232 patients with 270 mandibular fractures). The primary outcome variable was postoperative surgical wound dehiscence (SWD). Associations between patient-, fracture-, and surgery-related variables and SWD were studied. In Study IV, patients with one or two non-comminuted fractures of the dentate part of the mandible treated surgically via intraoral approach (n=34) were included. Patients in the study group received perioperative DXM. The control group received neither steroids nor placebo. The primary outcome variables were postoperative visual analogue scale (VAS) score, postoperative opioid medication, maximal mouth opening, and postoperative facial swelling. Results: SSI occurred in 18 patients (16.8%) in Study I. None of the studied patient-, fracture-, or surgery related variables showed significant differences between the groups. In Study II, postoperative surgical site complication was observed in 13 patients (31.7%). No significant differences in patient- and fracture-related variables or treatment-related variables were found between patients with and without postoperative complication. Recurrent infection was the most common surgical site complication (n=9, 69.2%). SWD without infection occurred only with intraoral approach (p=0.0380). Twenty-two SWDs were detected, occurring in 9.5% of patients and in 8.1% of fractures in Study III. A significantly greater SWD rate was observed only among smokers (p=0.0410). In surgery-related variables, night-time surgery showed a significantly higher SWD rate than daytime surgery (p=0.012). In Study IV, the VAS score was significantly lower in the study group 18 hours postoperatively (p=0.0330). No significant difference in the postoperative opioid medication, difference in percentage decrease in facial swelling, or mouth opening were found between the study and control groups. Conclusions: Postoperative surgical site complications are common in mandibular fracture patients. A significantly greater SWD rate was observed among smokers and patients treated at night-time. SSIs can occur despite adequate fracture treatment and antibiotic regimen. The duration of antibiotic treatment showed no significant difference between patients with or without SSI. Thus, short antibiotic treatment as part of the surgical treatment of mandibular fracture seems to be sufficient. Patient-related factors and delay caused by health care professionals for missed fracture were the most common reasons for infected mandibular fractures. Postoperative surgical site complications are common in patients with infected mandibular fracture. SWD without infection occurred exclusively with an intraoral approach. Both intraoral and extraoral approaches can be used, but patients should be selected with care and SWD risk in intraoral approach should be noted. The use of perioperative DXM reduces postoperative pain significantly in mandibular fracture patients 18 hours postoperatively. No significant effect on postoperative trismus or oedema was found. The analgesic effect seems to be short-term, and potential disadvantages of glucocorticoids should be considered.