Int. J. Oral Maxillofac. Surg. 2011; 40: 1373–1376 doi:10.1016/j.ijom.2011.08.008, available online at http://www.sciencedirect.com
Clinical Paper Trauma
Postoperative radiographs after maxillofacial trauma: Sense or nonsense?
B. van den Bergh, Y. Goey, T. Forouzanfar Department of Oral and Maxillofacial Surgery/ Oral Pathology, VU University Medical Center/ Academic Centre for Dentistry Amsterdam (ACTA), P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
B. van den Bergh, Y. Goey, T. Forouzanfar: Postoperative radiographs after maxillofacial trauma: Sense or nonsense?. Int. J. Oral Maxillofac. Surg. 2011; 40: 1373–1376. # 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. 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 fractures5,12. 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 reasons5,7, but there is little evidence for this justification1,3,5. The Royal College of Radiologists suggested that unnecessary radiation from 0901-5027/1201373 + 04 $36.00/0
diagnostic radiology causes 100–250 deaths from cancer every year worldwide10. Although it is stated that the risk from radiography is low, MEMON et al. found a significant association between dental X-ray exposure and the risk of thyroid cancer8. 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
Key words: postoperative; radiography; maxillofacial trauma. Accepted for publication 31 August 2011 Available online 1 October 2011
development of tumours in the brain and parotid gland6,11,13. In contrast, RODVALL et al. did not find clear evidence associating radiographs with brain tumours15. RON 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 applicable16. In conclusion, the relationship between maxillofacial radiographic analysis and elevated cancer risk is debatable. According to the ALARA (as low as reasonably
# 2011 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
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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 information7. Another questionable aspect of taking postoperative radiographs is described by DURHAM et al.5 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 unnecessary1–3,5. 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 treatment2. 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.
Table 1. Maxillofacial fractures treated surgically. Type of fracture
No.
Fracture of the mandible Fracture of the zygomatic complex Fracture of the zygomatic arch Le Fort I Le Fort II Le Fort III Panfacial fracture Fracture of the frontal sinus Blow-out fracture Total
270 243 23 19 14 7 37 18 15 646
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. 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. The third patient presented with a dislocated zygomatic arch fracture. After closed reduction the radiographic analysis
Table 2. Demographics of retreated patients. Patient
Time of retreatment
Type of fracture
Cause of retreatment
Retreatment
Decision based on
1
Before discharge
Panfacial trauma
Reposition and fixation
Clinical signs
2 3 4 5 6 7 8
Before discharge Before discharge Within 2 weeks Within 2 weeks Within 2 weeks Within 2 weeks Within 4 weeks
Zygomatic Zygomatic Mandible Mandible Mandible Zygomatic Zygomatic
Poor reposition zygomatic complex Poor reposition and fixation Poor closed reduction Malocclusion Malocclusion Malocclusion Poor closed reduction Diplopia and enophthalmia
Clinical signs Radiographics Clinical signs Clinical signs Clinical signs Clinical signs Clinical signs
9
Within 4 weeks
Zygomatic complex
Diplopia and enophthalmia
10
Within 4 weeks
Zygomatic complex
Diplopia and enophthalmia
11 12 13 14 15
Within 4 weeks After 4 weeks After 4 weeks After 4 weeks After 4 weeks
Panfacial trauma Mandible Pure blow-out Pure blow-out Zygomatic complex
Malocclusion Malocclusion Diplopia Enophthalmia Diplopia and enophthalmia
16
After 4 weeks
Frontal sinus
Malpositioned frontal sinus wall
Reposition and fixation Elevation Reposition and fixation Reposition and fixation Reposition and fixation Reposition and fixation Secondary reconstruction of the orbital floor Secondary reconstruction of the orbital floor Secondary reconstruction of the orbital floor Reposition and fixation Unilateral sagittal split osteotomy Shortening orbital floor transplant Changing position transplant Secondary reconstruction of the orbital floor Reshaping of the frontal sinus
complex arch
complex complex
Clinical signs Clinical signs Clinical Clinical Clinical Clinical Clinical
signs signs signs signs signs
Clinical signs
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Postoperative radiography after maxillofacial trauma 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 com-
plex). 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. Discussion
The purpose of the present study was to investigate the necessity of postoperative radiographic analysis in patients with maxillofacial trauma. A retrospective analysis was made of all maxillofacial trauma surgically treated in the last 10 years in the authors’ institute. 579 patients were treated for 646 fractures; in 16 patients (3%) a secondary treatment was needed as the initial treatment did not result in proper repositioning and fixation. The decision regarding retreatment was mainly based on clinical findings (15 patients, 94%). For one patient (6%) the decision to retreat was based on radiographical findings only. This patient was treated immediately after the initial reposition as radiographic ana-
lysis demonstrated a suboptimally elevated zygomatic arch. A search in the US National Library of Medicine Database (PubMed) was carried out to identify articles written in English concerning postoperative radiography in maxillofacial trauma. All studies assessing data for evaluation of the necessity for taking postoperative radiographs in maxillofacial trauma were included. The search strategy resulted in 6 useful studies1,2,4,5,7,12. Three studies were prospective,4,5,7 two were retrospective2,12 and one was combined prospective/retrospective1. One study conducted a multicentre trial7. In these studies different ‘populations’ were analysed. One study researched solitary mandible fractures,5 two studied solitary zygomatic bone fractures4,12 and one study investigated both solitary mandible and solitary zygomatic bone fractures.2 All types of maxillofacial fractures were analysed by two studies1,7. All studies excluded complex craniofacial trauma. The postoperative follow-up ranged from immediately postoperatively to 3 months postoperatively. 1377 patients (range 30–431) underwent surgery for correction of a maxillofacial fracture (Table 3). Nine patients returned to the operating theatre for correction of the initial procedure after trauma (0.7%). In all patients, the decision to revise was based solely on the clinical findings. The authors of these 6 studies concluded that clinical judgement alone is sufficient for the postoperative evaluation of maxillofacial fractures. The present results are in line with the available literature, but they show a relatively high number of retreatments, which can probably be explained by the prolonged follow-up compared to the other studies. In the present study, complex craniofacial trauma is also included. Several authors postulated arguments for performing postoperative radiographs, including surgical treatment evaluation and detection of defects after surgery before the patient is discharged5,7. As the treatment of facial fractures has changed in recent years from closed reduction with fixation to mainly open reduction
Table 3. Studies concerning postoperative imaging. Author
Year
Type of study
Type of fracture
DURHAM et al. JAIN et al. CRIGHTON et al. BALI et al. CHANDRAMOHAN OGDEN et al. Total
2006 2009 2006 2004 2007 1988
Prospective Prospective Prospective Prospective/retrospective Retrospective Retrospective
Mandible All types of fractures Zygoma All types of fractures Mandible + zygoma Zygoma
No. of patients 100 431 30 257 376 183 1377
Retreatments 0 2 0 3 3 1 9
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with fixation the benefit of postoperative radiographic analysis is questionable1. Fracture lines can be judged directly during surgery and therefore postoperative radiographs will not supply more information. In multiple facial injuries (e.g. panfacial trauma) it can sometimes be difficult to visualize every bone fragment during reduction. In these multiple facial injuries the surgeon may consider taking postoperative radiographs. Further postoperative radiographs are advised to prevent judicial complications. According to JAIN et al., if observation of the fracture lines during surgery and the results of clinical findings are documented well, there is adequate evidence for a correct treatment and therefore postoperative radiography is unnecessary7. As judicial aspects are out of the scope of the authors’ expertise this subject will not be discussed further. Another reason used to justify standard postoperative imaging is registration of used osteosynthesis material for possible removal in the future. In the authors’ opinion this can be performed when the decision is made to remove the osteosynthesis. The present data did not demonstrate that avoiding routine postoperative radiographs will lead to a more efficient discharge. In the authors’ institute most patients surgically treated in the afternoon stay overnight. This is dictated by the protocol of the institute and influenced by clinic-related factors (e.g. logistics, paramedical capacity). As a result of this process, patients are not discharged until the next morning after taking postoperative radiographs. The authors’ institute is a university hospital and the department of oral and maxillofacial surgery has healthcare and educational obligations. For educational purposes pre- and postoperative radiographs are indispensable. Interpretation of radiographs is stated to improve during the first years of practice9,14. No information exists whether performing or interpreting radiographs in maxillofacial trauma will add to the learning curve of residents of oral and maxillofacial surgery. Nevertheless in the authors’ opinion it is justified to take routine radiographs in a teaching hospital for this educational purpose. The consequence of this opinion is that radiographs are made when a patient is admitted to a teaching hospital and not a non-teaching hospital. This is a controversial and ethical matter but in everyday practice this is already the case. The present retrospective study contains data for all maxillofacial trauma including complex maxillofacial trauma and has the
largest population of all studies published. Like other retrospective studies this analysis may lead to information bias. Despite this shortcoming, the results presented are in line with other studies and the analysis of this report provides important data to support the elimination of standard postoperative radiographs as proposed by previous authors. It is questionable to perform 1097 postoperative radiographs to identify 1 patient needing a secondary treatment after the initial reposition based on radiographic analysis alone. Intra-operative analysis of the reposition and the immediate postoperative clinical symptoms are better indicators for evaluating the adequacy of treatment. Postoperative imaging should be reserved for patients with complaints or physical findings suggesting complications4. Taking postoperative radiographs may be considered in multiple facial injuries and for educational purposes in a teaching hospital. Nevertheless avoiding performing routine postoperative radiographs will lead to a reduction in exposure of patients to ionizing radiation. Further benefits of avoiding routine postoperative radiographs include cost savings and probably more efficient discharge. Funding
None. Conflict of interest
None declared. Ethical approval
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[email protected]
