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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 15-19

Appropriateness of immediate postoperative radiographs after open reduction and internal fixation of simple maxillofacial fractures––a retrospective audit


1 Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission26-Jun-2019
Date of Decision16-Aug-2019
Date of Acceptance20-Aug-2019
Date of Web Publication25-Feb-2020

Correspondence Address:
Dr. Ravindranath Vineetha
Department of Oral Medicine and Maxillofacial Radiology, Manipal College of Dental Sciences, Manipal, Manipal Academy of Higher Education, Manipal 576104, Karnataka.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jioh.jioh_170_19

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  Abstract 

Aim: Immediate postoperative radiographs are routinely advised by surgeons for treatment of maxillofacial fractures. It is mainly for evaluation of the reduced fracture, alignment of plates, and assessment of occlusion. To scrutinize the requirement of routine postoperative radiography in patients treated by open reduction and internal fixation of fracture. Materials and Methods: The study was conducted retrospectively and radiographs of the patients who had reported to emergency department of our institute because of maxillofacial trauma from 2014 to 2016 were retrieved from the archive of dental radiology department. A total of 147 subjects were treated for 203 simple maxillofacial fractures. Information on age, gender, type of fracture, site of fracture, treatment carried out, and cause of retreatment if any were recorded. The continuous variables (age and number of fractures) were compared using the Mann–Whitney U test, whereas the Fisher’s exact test was used to compare categorical variables (gender and type of management). Results: The number of subjects that required re-treatment surgeries was evaluated. Only 13 subjects required re-treatment surgeries. Only in one subject (0.49%), the decision for re-treatment was based exclusively on postoperative radiographs. Six studies from the literature reported that postoperative occlusion can better predict the clinical outcome instead of immediate postoperative radiograph. The results of this study are in accordance with the literature review. Conclusion: Routine immediate postoperative radiograph may not be essential after management of simple maxillofacial fractures. Immediate postoperative radiographs may be indicated for subjects with possibility of complications.

Keywords: Dental, Immediate, Maxillofacial, Postoperative, Radiographs, Trauma


How to cite this article:
Smriti K, Gadicherla S, Kamath AT, Pentapati KC, Vineetha R, Singh A. Appropriateness of immediate postoperative radiographs after open reduction and internal fixation of simple maxillofacial fractures––a retrospective audit. J Int Oral Health 2020;12:15-9

How to cite this URL:
Smriti K, Gadicherla S, Kamath AT, Pentapati KC, Vineetha R, Singh A. Appropriateness of immediate postoperative radiographs after open reduction and internal fixation of simple maxillofacial fractures––a retrospective audit. J Int Oral Health [serial online] 2020 [cited 2022 Jan 18];12:15-9. Available from: https://www.jioh.org/text.asp?2020/12/1/15/279216




  Introduction Top


Radiographs have been an integral part of diagnosis and treatment planning of maxillofacial fractures. Advising immediate postoperative radiographs is a common practice followed by oral and maxillofacial surgeons after treatment of maxillofacial fractures. The rationale for following such routine practice is to evaluate the surgically reduced site and proper plating of the defect. The proponents for such practice also opine that such radiographs may be useful for training residents and students and as regular documentation for medicolegal cases.

According to “As low as reasonably achievable” (ALARA) principle, unnecessary exposure of X-rays always has an added risk of cancer development. Although the risk from a diagnostic radiograph is low, incidence of stochastic effect cannot be ignored. Menon et al.[1] found a positive correlation between dental X-ray exposure and thyroid cancer.

The guidelines laid down by the National Radiographic Protection Board[2] and the Royal College of Radiologists[3] state that a specific indication must exist for taking a radiograph, which will result in a change in management. Childres and Newlands[4] in their study found that radiographs only contribute to diagnosis of fracture of the maxillofacial region and do not give any hint of complication. Over the years, surgical skill advancement has caused a shift of management of fracture from closed reduction to open reduction and internal fixation (ORIF). In that case, intraoperative alignment of the fractured segment and postoperative occlusion can predict better clinical outcome rather than immediate postoperative radiographic imaging. Routine immediate postoperative radiographs can cause delay in discharge from the hospital, extra stay, and incur substantial expenditure to the patients.[1] Even though there seems to exist a consensus among the clinicians to avoid routine postoperative radiographs for simple maxillofacial fractures, many surgeons still continue to use them for reasons mentioned earlier.

Even though it is imperative that routine postoperative radiographs may not affect patient outcomes, studies have not been conducted on the current postoperative maxillofacial radiograph ordering practices in Indian context. It is still a matter of debate that immediate postoperative radiographs influence the decision of immediate correction of the defect by returning to the operation theatre. Given the above facts, we aimed to audit the immediate postoperative radiograph requisition practices after ORIF of simple maxillofacial fractures patients with maxillofacial fractures at our tertiary care center.


  Materials and Methods Top


This descriptive study (retrospective audit) was conducted in oral medicine and radiology department of our institution. Radiographs of the patients who had reported to emergency department of our institution because of maxillofacial trauma between November 2014 and November 2015 were retrieved from the archive of dental radiology department.

Patients of both sexes who underwent ORIF as treatment of maxillofacial fractures under general anesthesia were included. Subjects with panfacial fractures, dentoalveolar fractures, nose fractures, and pathological fractures because of other comorbidities were excluded from the study. Patients who underwent closed reduction for the fractures were also excluded from the study.

A total of 1300 radiographs were screened during the study period from which 470 radiographs of the patients who had maxillofacial trauma were selected. Radiographs that were not readable or processing or positioning errors (n = 17) and patients with panfacial trauma were excluded in the study (n = 73). Final sample constituted of 204 radiographs (for various fracture sites) having simple maxillary and mandibular fractures obtained from 147 patients were included in this study. The preoperative and postoperative panoramic radiographs along with the discharge summary were reviewed and evaluated retrospectively. The list of patients who underwent retreatment was prepared and the causes for retreatment of fractures were analyzed. The data were collected in a specially designed profoma, which included age, gender, type of fracture, site of fracture, treatment carried out, and cause of retreatment if any.

Routine postoperative radiographs were taken for all the patients prior to discharge. All radiographs were evaluated by a senior oral and maxillofacial surgeon as well as an oral radiologist to evaluate the usefulness of postoperative radiographs to determine the clinical course of the fracture healing and adequacy of fracture reduction.


  Statistical Analysis Top


All the analysis was performed using Statistical Package for the Social Sciences software version 16.0 (SPSS, Chicago, IL). Descriptive statistics were calculated and presented as frequencies and percentages. The Mann–Whitney U test was used to compare the age and number of fractures between the groups, whereas the Fisher’s exact test was used to compare the gender and type of management between the groups.


  Results Top


A total of 147 subjects were treated for 204 maxillofacial fractures by ORIF under general anesthesia [Table 1]. The most often advised immediate postoperative radiographs for the operated patients were orthopantomograms, water’s view, and submentovertex view. All postoperative radiographs routinely advised after surgery were properly evaluated, which revealed that only 13 patients (8.8%) required surgical retreatment. The radiographs of the patients who underwent re-treatments were segregated and cause for undergoing retreatment was assessed [Figure 1]A and B. The decisions of retreatment based exclusively on postoperative imaging were considered for three patients (2%). One patient was treated again during the same hospital stay who had zygomatic arch fracture, as he developed trismus. Two patients had angle fracture who developed restricted mouth opening and improper bite, respectively. Seven patients were re-operated within three weeks of discharge based exclusively on clinical features. Three patients were retreated after one month who reported with complaint of malocclusion and inability to open mouth [Table 2].
Table 1: Distribution of patients with surgical management of maxillofacial fractures

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Figure 1: (A) Preoperative radiograph showing angle fracture on the left side. (B) Immediate postoperative radiograph showing inadequately reduced left angle fracture

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Table 2: Summary of retreated patients

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We have compared age, gender, number of fracture, and management between primary and retreated cases. No significant difference was found in the mean age between the groups (P = 0.503). The number of fracture was significantly higher in the retreatment group than the primary treatment group (P = 0.038). No significant difference was found in the distribution of gender and type of management between the groups (P > 0.99 and 0.623), respectively [Table 3].
Table 3: Comparison of age, gender, number of fractures, and type of management between the groups

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  Discussion Top


Recommending immediate postoperative radiographs by maxillofacial surgeons after the treatment of facial fractures is mainly custom driven as a part of conventional practice, which shows conventional tradition of defensive medicine. The proposed reason of indication of postoperative radiographs is for assessment of fracture reduction, to keep documentation of the patients, for teaching personnel and students, as well as medicolegal cases.

Previously, closed reduction was commonly done to treat fractures that occur to be a blind procedure; thus, immediate postoperative radiographs were required to assess the accuracy of fracture reduction. However, the modality of treatment has shifted from closed reduction and indirect fixation to ORIF, where the intraoperative criteria such as occlusion, fractured segment approximation, and proper fixation through plating can better predict the treatment outcome.[5]

The National Council of Radiological Protection in its guidelines for diagnostic medical and dental X-ray shows that investigations using ionizing radiation are always associated with increased threat of long-term development of malignant disease and harmful mutations causing hereditary disease.[2],[6] It is absolutely necessary to keep in account the probable harm due to even the lowest amount of absorbed radiation dose. It is always advisable to avoid such exposure to patient, which has no added benefit. A study conducted at Royal College of Radiologist suggested that although risk associated from dental radiography is less, three studies conducted by them have indicated probable relation between dental X-ray and incidence of parotid tumors and brain tumors.[7],[8] On the contrary, Rodvall et al.[9] found no association of dental radiographs with brain tumors. The effect of radiation-associated cancer risk using routine epidemiological methods could not be studied easily as the doses diagnostic radiographs are low.[10] Study conducted in our institution retrospectively analyzed radiographs of 147 patients who underwent treatment for maxillofacial trauma over one-year duration. Total 204 fracture sites were treated by ORIF under general anesthesia for which 217 X-rays were taken preoperatively and 152 radiographs were taken as immediate postoperative radiograph. Only orthopantomograms were considered for the study.

Only 13 patients (8.8%) required re-treatment surgery as the primary surgery did not result in proper alignment and occlusion. Re-treatment decision was based on clinical signs and symptoms (76%). For only three patients, the treatment was solely based on immediate postoperative radiograph and was reoperated during the same hospital stay.

Literature search using all databases revealed six useful studies, which reported that postoperative occlusion can better predict the clinical outcome instead of immediate postoperative radiograph.[1],[4],[11],[12],[13],[14] Three of these studies were prospective, two were retrospective, and one of them was combined prospective and retrospective in study design. With advancement in imaging technology, at some centers it has become a norm to take a postoperative computed tomography (CT) scan instead of routine radiographs. In a study published regarding usage of postoperative CT scans, the authors opined that clinician’s individual practice was most important factor determining whether patient received postoperative imaging. The results of this study were in accordance with the literature. This study revealed that routine immediate postoperative radiograph was taken for all the patients but only three patients (1.47%) were retreated exclusively based on radiograph. Hence, it is not prudent to expose the patients to ionizing radiation.[15] Evidence-based practice guidelines should be formulated based on further studies elsewhere. Further prospective studies can be recommended incorporating other complex fractures and their treatment outcomes and the usefulness of the immediate postoperative radiographs. Also, collaborative multicentric can be planned to evaluate the same.

Postoperative radiographs may not provide any insight regarding adequacy of fixation.[13] Durham et al.[16] reported that only 57% of the immediate postoperative radiographs were reviewed by a consultant which suggested that rest of the 43% patients were discharged from hospital without the analysis of radiographs.

In complex facial trauma (e.g., pan-facial trauma), it is not feasible to evaluate reduction and fixation of all the fragments. In such instances, it may be prudent to take postoperative radiographs to check the adequacy of reduction. Other cited reason for postoperative radiographs is to have a record of used material for future reference.[17]

For educational and training purposes, these radiographs are extremely useful. However, no evidence exists whether such an exercise adds to the learning curve of resident surgeons.[18],[19] Nevertheless, even for training purpose checking few sets of radiographs should suffice rather than making postoperative radiograph a standard protocol.

Our results not only corroborate the findings of previous studies, in that there were no significant differences in outcomes or complications between patients with and without postoperative radiograph, but also may indicate that it is difficult for surgeons to change a long-term clinical practice even if literature may indicate the otherwise. However, there were limitations in this study because of its retrospective design. The possibility of not reporting adverse outcomes after surgery to the same centre (lost to follow-up) cannot be ruled out.


  Conclusion Top


Routine immediate postoperative radiograph may not be essential after surgery of maxillofacial simple fractures. Intraoperative criteria including proper occlusion and accurate reduction of the fractured segment are better predictors of healing fracture. It also reduces the cost of stay in the hospital and radiation exposure.

Our study has one of the largest population of all studies published on simple maxillofacial fractures. However, the possibility of information bias cannot be ruled out in retrospective studies. Nevertheless, the results from our study are in line with previous studies, which contraindicate the need for immediate postoperative radiographs. It is author’s take that postoperative radiographs may be indicated for subjects with possibility of complications.

Ethical policy and institutional review board statement

The study was approved by Institutional Ethics Committee of Kasturba Medical College and Kasturba Hospital, Manipal (IEC No: 429/2016). All the procedures have been performed as per the ethical guidelines laid down by Declaration of Helsinki (2013).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bali N, Lopes V. An audit of the effectiveness of postoperative radiographs––Do they make a difference? Br J Oral Maxillofac Surg 2004;42:331-4.  Back to cited text no. 1
    
2.
Guidance Notes for Dental Practitioners on the Safe Use of X-Ray Equipment. Chilton: National Radiological Protection Board; 2001.  Back to cited text no. 2
    
3.
Remedios D, France B, Alexander M. Making the best value of clinical radiology: iRefer Guidelines, 8th edition. Clin Radiol 2017;72:705-7.  Back to cited text no. 3
    
4.
Childress CS, Newlands SD. Utilization of panoramic radiographs to evaluate short-term complications of mandibular fracture repair. Laryngoscope 1999;109:1269-72.  Back to cited text no. 4
    
5.
Chakravarthy J, Mangat K, Qureshi A, Porter K. Postoperative radiographs following hip fracture surgery: Do they influence patient management? Int J Clin Pract 2007;61:421-4.  Back to cited text no. 5
    
6.
National Radiation Laboratory (N.Z.). Guidelines on Patient Dose to Promote the Optimisation of Protection for Diagnostic Medical Exposures. Chilton: National Radiation Laboratory; 1999.  Back to cited text no. 6
    
7.
Neuberger JS, Brownson RC, Morantz RA, Chin TD. Association of brain cancer with dental X-rays and occupation in Missouri. Cancer Detect Prev 1991;15:31-4.  Back to cited text no. 7
    
8.
Horn-Ross PL, Ljung BM, Morrow M. Environmental factors and the risk of salivary gland cancer. Epidemiology 1997;8:414-9.  Back to cited text no. 8
    
9.
Rodvall Y, Ahlbom A, Pershagen G, Nylander M, Spännare B. Dental radiography after age 25 years, amalgam fillings and tumours of the central nervous system. Oral Oncol 1998;34:265-9.  Back to cited text no. 9
    
10.
Ron E. Cancer risks from medical radiation. Health Phys 2003;85:47-59.  Back to cited text no. 10
    
11.
Ogden GR, Cowpe JG, Adi M. Are post-operative radiographs necessary in the management of simple fractures of the zygomatic complex? Br J Oral Maxillofac Surg 1988;26:292-6.  Back to cited text no. 11
    
12.
Crighton LA, Koppel DA. The value of postoperative radiographs in the management of zygomatic fractures: Prospective study. Br J Oral Maxillofac Surg 2007;45:51-3.  Back to cited text no. 12
    
13.
Jain MK, Alexander M. The need of postoperative radiographs in maxillofacial fractures––a prospective multicentric study. Br J Oral Maxillofac Surg 2009;47:525-9.  Back to cited text no. 13
    
14.
Chandramohan J, McLoughlin PM. Fractures of the mandible and zygomatic complex: Postoperative radiographs are not necessary. Br J Oral Maxillofac Surg 2007;45:90.  Back to cited text no. 14
    
15.
Courtemanche DJ, Barton R, Li D, McNeill G, Heran MKS. Routine postoperative imaging is not indicated in the management of mandibular fractures. J Oral Maxillofac Surg 2017;75:770-4.  Back to cited text no. 15
    
16.
Durham JA, Paterson AW, Pierse D, Adams JR, Clark M, Hierons R, et al. Postoperative radiographs after open reduction and internal fixation of the mandible: Are they useful? Br J Oral Maxillofac Surg 2006;44:279-82.  Back to cited text no. 16
    
17.
van den Bergh B, Goey Y, Forouzanfar T. Postoperative radiographs after maxillofacial trauma: Sense or nonsense? Int J Oral Maxillofac Surg 2011;40:1373-6.  Back to cited text no. 17
    
18.
Miglioretti DL, Gard CC, Carney PA, Onega TL, Buist DS, Sickles EA, et al. When radiologists perform best: The learning curve in screening mammogram interpretation. Radiology 2009;253:632-40.  Back to cited text no. 18
    
19.
Ripsweden J, Mir-Akbari H, Brolin EB, Brismar T, Nilsson T, Rasmussen E, et al. Is training essential for interpreting cardiac computed tomography? Acta Radiol 2009;50:194-200.  Back to cited text no. 19
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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