Journal of Oral and Maxillofacial Surgery最新文献

Nasotracheal intubation is crucial for many oral and maxillofacial surgery procedures; however, it presents more challenges than orotracheal intubation and requires a higher level of training, along with various execution options. The routine use of an endotracheal tube (ETT)-first nasal fiberoptic intubation protocol is recommended, specifically in cases where orotracheal intubation is not possible or feasible. In this proposed technique, 137 randomly selected patients underwent fiberoptic nasotracheal intubation for general anesthesia utilizing a strict ETT first protocol. The mean preintubation ETT depth was 14 cm from the nares, correlating this distance with the patient's height, weight, and gender, proposing a formula for depth selection. Inserting the nasal ETT to a mean depth of 14 cm prior to insertion of the fiberoptic scope resulted in excellent visualization of the glottis with a first pass success rate for intubation of 97.8% and a mean intubation time of 68.5 seconds, regardless of the expertise of the provider.

Background: While artificial intelligence has significantly impacted medicine, the application of large language models (LLMs) in oral and maxillofacial surgery (OMS) remains underexplored.

Purpose: This study aimed to measure and compare the accuracy of 4 leading LLMs on OMS board examination questions and to identify specific areas for improvement.

Study design, setting, and sample: An in-silico cross-sectional study was conducted to evaluate 4 artificial intelligence chatbots on 714 OMS board examination questions.

Predictor variable: The predictor variable was the LLM used - LLM 1 (Generative Pretrained Transformer 4o [GPT-4o], OpenAI, San Francisco, CA), LLM 2 (Generative Pretrained Transformer 3.5 [GPT-3.5], OpenAI, San Francisco, CA), LLM 3 (Gemini, Google, Mountain View, CA), and LLM 4 (Copilot, Microsoft, Redmond, WA).

Main outcome variables: The primary outcome variable was accuracy, defined as the percentage of correct answers provided by each LLM. Secondary outcomes included the LLMs' ability to correct errors on subsequent attempts and their performance across 11 specific OMS subject domains: medicine and anesthesia, dentoalveolar and implant surgery, maxillofacial trauma, maxillofacial infections, maxillofacial pathology, salivary glands, oncology, maxillofacial reconstruction, temporomandibular joint anatomy and pathology, craniofacial and clefts, and orthognathic surgery.

Covariates: No additional covariates were considered.

Analyses: Statistical analysis included one-way ANOVA and post hoc Tukey honest significant difference (HSD) to compare performance across chatbots. χ² tests were used to assess response consistency and error correction, with statistical significance set at P < .05.

Results: LLM 1 achieved the highest accuracy with an average score of 83.69%, statistically significantly outperforming LLM 3 (66.85%, P = .002), LLM 2 (64.83%, P = .001), and LLM 4 (62.18%, P < .001). Across the 11 OMS subject domains, LLM 1 consistently had the highest accuracy rates. LLM 1 also corrected 98.2% of errors, while LLM 2 corrected 93.44%, both statistically significantly higher than LLM 4 (29.26%) and LLM 3 (70.71%) (P < .001).

Conclusion and relevance: LLM 1 (GPT-4o) significantly outperformed other models in both accuracy and error correction, indicating its strong potential as a tool for enhancing OMS education. However, the variability in performance across different domains highlights the need for ongoing refinement and continued evaluation to integrate these LLMs more effectively into the OMS field.

Background: Temporomandibular joint (TMJ) advanced arthroscopic debridement (level II arthroscopy) is a minimally invasive procedure involving microsurgical debridement of degenerated tissues with aid of a fiber-optic camera. Its use for treating intra-articular pain and dysfunction (IPD) in advanced TMJ degenerative disease remains debated.

Purpose: The primary purpose was to evaluate if level II arthroscopy was associated with improvement in pain and quality of life in subjects with advanced TMJ degenerative disease, and to identify clinical factors that influence outcomes.

Study design, setting, sample: This was a retrospective cohort study conducted on subjects who presented to the University of Michigan oral and maxillofacial surgery clinic between November 2020 and July 2023 who required arthroscopy for IPD. Inclusion criteria were unilateral or bilateral IPD, Wilkes V disease, arthroscopically verified disc perforation, and 3-month minimum follow-up. Subjects with level I/III arthroscopy or with Wilkes I-IV disease were excluded.

Covariates: The covariates included demographics (age, sex), preoperative variables (body mass index, allergies, environmental sensitivities, condylar degeneration, systemic arthropathy, serology, prior arthrocentesis, preoperative jaw functional limitation scale (JFLS) and pain), and operative variables (synovitis, chondromalacia, adhesions, laterality, debridement, and injections).

Main outcome variables: Primary outcomes were changes in quality of life and pain measured via the JFLS and visual analog pain scale, respectively, at minimum 3-month post-arthroscopy.

Analyses: Linear regression analyzed JFLS with covariates, and linear-mixed effects models adjusted for nonindependent pain from bilateral TMJ sides. Paired t-tests compared mean JFLS and pain scores with significance set at P < .05.

Results: A total of 240 subjects were screened and 40 subjects completed the study with mean age of 49.33 (±13.62) years, 95% subjects were female, and median follow-up of 7 months (interquartile range 6 to 8). Mean JFLS decreased from 73.3 (±34.94) to 43.8 (±35.35) postoperatively (P < .0001). Mean pain scores decreased from 60.0 (±21.2) to 38.0 (±28.5) postoperatively (P < .0001). Environmental sensitivity was the only covariate significantly associated with higher postoperative JFLS (P = .002). Three subjects (7.5%) required total arthroplasty post-level II arthroscopy.

Conclusion and relevance: Advanced arthroscopic debridement (level II arthroscopy) is associated with reduced pain and improved quality of life in subjects with Wilkes V degenerative joint disease.

Purpose: Virtual surgical planning (VSP) has significantly transformed craniomaxillofacial surgery over the past 2 decades, leading to diverse applications and improved surgical outcomes. However, variations in technological approaches, clinical outcomes, and economic implications persist. This review aims to comprehensively examine the evolution of VSP in craniomaxillofacial surgery, assess its impact on surgical precision and patient outcomes, and identify current trends and future directions. A synthesis of current knowledge is essential to establish evidence-based guidelines for VSP implementation and optimize patient care in this rapidly advancing field.

Methods: A systematic literature search was conducted in PubMed, Embase, and IEEE Xplore databases from their inception to September 2024. Search terms included combinations of "virtual surgical planning" OR "computer-assisted surgery" AND "craniomaxillofacial" OR "maxillofacial" OR "craniofacial" AND "evolution" OR "development" OR "advancement". From 540 initially identified articles, studies focusing on VSP in craniomaxillofacial surgery that reported technological advancements, surgical outcomes, or precision metrics were included. Eligible studies comprised case series with 5 or more subjects, comparative studies, and validation studies. Data extraction included study characteristics, technology details, surgical applications, outcome measures, and economic factors. Quality assessment was performed using appropriate tools based on study design.

Results: Out of 540 articles, 36 studies spanning from 1999 to 2024 met the inclusion criteria. The evolution of VSP was categorized into 3 phases: early foundations (1999 to 2004), expansion of applications and improved accuracy (2005 to 2014), and advanced integration with emerging technologies (2015 to 2024). Orthognathic surgery was the commonest application (52.8% of studies), followed by tumor resection and reconstruction (22.2%). Studies consistently demonstrated smaller linear discrepancies between planned and actual outcomes with VSP compared to conventional methods (VSP: 0.04 to 0.25 mm vs conventional: 0.29 to 1.33 mm). Recent advancements include the integration of artificial intelligence, mixed reality, and robotic systems, enhancing both preoperative planning and intraoperative guidance.

Conclusion: VSP has considerably evolved in craniomaxillofacial surgery, improving accuracy as demonstrated by reduced linear discrepancies between planned and actual outcomes across various procedures. While promising, challenges remain, including the need for standardization, comprehensive cost-effectiveness analyses, and long-term outcome studies.

Background: Midface reconstruction poses challenges due to significant blood loss and difficulty in achieving intraoperative hemostasis, often necessitating blood transfusions. Various agents, most notably tranexamic acid (TXA), have been utilized intraoperatively to mitigate this risk of bleeding and transfusion-related complications.

Purpose: The study purpose was to measure the association of TXA with blood loss and transfusion requirements during craniofacial procedures involving the midface.

Study design, setting, sample: This project was designed as a retrospective cohort study. Patients who underwent midface reconstruction at Children's Hospital Los Angeles between 2010 and 2023 were included, and a retrospective chart review was conducted.

Independent variable: The independent variable was weight-adjusted TXA exposure divided into 2 groups: subjects who received TXA preoperatively and intraoperatively and those that did not.

Main outcome variables: The main outcome variables were weight-adjusted intraoperative blood loss and transfusion requirements. Secondary outcomes included intraoperative and postoperative complications and length of stay.

Covariates: Demographic covariates included age at surgery, sex, weight, and syndromic status. Operative covariates covered the type of surgical approach and main procedure performed. Perioperative covariates included anesthesia time and operative time.

Analyses: Parametric and nonparametric variables were analyzed using independent t-test and Wilcoxon rank-sum test, respectively. χ² analysis was used to analyze categorical variables, and multivariable linear regressions were performed. A P value of less than .05 was considered statistically significant.

Results: A total of 80 patients underwent midface reconstruction surgery, 37 (46.3%) of whom received TXA and 43(53.7%) did not. The mean age at surgery was 8.7 ± 3.8 years in the TXA cohort and 11.6 ± 5.1 years in the non-TXA cohort (P = .02). Multivariable regression analysis further demonstrated a statistically significant association between the administration of TXA and both reduced blood loss (coefficient -0.14 [95% CI -0.20 to -0.07], P < .01) as well as reduced transfusion requirement (coefficient -0.14 [95% CI -0.19 to -0.08], P < .01). There was no increased risk of complications, such as thromboembolic events or seizures, in patients who were administered TXA (P = .14).

Conclusion and relevance: TXA is likely a valuable adjunct for improving intraoperative and postoperative outcomes of craniofacial procedures involving the midface.

Between July 2021 and February 2024, 6 patients with biopsy-confirmed benign pathologic lesions had mandibular defects reconstructed using a reamer-irrigator-aspirator at the University of Cincinnati Medical Center. Patients' ages ranged from 34 to 73, 5 of which were males and one female. Primary end points were bony continuity of the mandible, recovery time, and ability of the graft to receive implants. The reamer-irrigator-aspirator obtained 40 to 100 cm³ of uncompressed bone from donor sites. All patients ambulated on the day of surgery or postoperative day one. No neurosensory disturbances were reported at the donor site. Five patients achieved radiographic continuity of the mandible postoperatively. Of the patients with continuity, 4 received implants, and one received a removable prosthesis. The patient without mandibular continuity declined further intervention and received a removable prosthesis. The findings lend support to the possibility of harvesting medullary bone from the femur for mandibular defect reconstruction.