For hospitals in New York City to improve unclear mandibular margins, these ones can be considered!

Introduction

Clear mandibular margins are crucial for proper dental and oral - maxillofacial health. In New York City, hospitals face the challenge of dealing with patients having unclear mandibular margins. Various factors can lead to this, such as fractures, atrophic conditions, and misalignments. This article will explore different approaches and procedures that hospitals in New York City can consider to improve unclear mandibular margins, including dental implants, orthognathic surgery, and the management of mandibular fractures.

Understanding Unclear Mandibular Margins

Unclear mandibular margins can present in multiple ways. It could be due to a decrease in the size of the mandibular ridge, which might be associated with an atrophic edentulous mandible. According to Quizlet study materials, a patient who has a very small, or essentially no mandibular ridge, is said to have an atrophic edentulous mandible. These patients often experience problems with denture fit, chewing, and overall oral function.

Another cause could be fractures in the mandible. Mandibular condylar fractures, which account for about 29% - 52% of all mandibular fractures, can disrupt the normal structure and alignment of the mandible, leading to unclear margins. The consequences of such fractures include mandibular movement disorders, temporomandibular joint (TMJ) dysfunction, malocclusion, and chewing dysfunction, all of which can affect the patient's physiological function and mental health.

Options for Improving Unclear Mandibular Margins

Dental Implants

Dental implants can be a viable solution for some patients with unclear mandibular margins. They provide a more stable and natural - looking replacement for missing teeth. Titanium is the most commonly used material for dental implants as it exhibits osseointegration, which is the process of successful integration of the implant with the bone. This transfers biting forces to the bone and stimulates the growth of bone, ensuring the longevity and function of the implant.

There are different types of dental implants. Endosseous implants involve cutting a hole into the alveolar bone and then pressing or screwing in the implant. Transosseous implants consist of a plate and several bolts that transverse the mandible, while subperiosteal implants are placed on the mandibular bone below the periosteum. However, not all patients are suitable candidates for dental implants. Contraindications for implant placement include recurrent caries, poor oral hygiene, diabetes, and smoking.

For patients with implants, post - care maintenance is essential. This includes necessary chairside and home - care instruction, recommended auxiliary aids, and a specific length of time between recall visits. The patient's home - care regimen may consist of a toothbrush and floss, and without proper maintenance, the possibility of implant failure greatly increases.

Orthognathic Surgery

Orthognathic surgery is a procedure that can help correct misaligned jaws, which may be the cause of unclear mandibular margins. At Mount Sinai in New York City, corrective jaw surgery for overbites, underbites, and cross - bites is a common procedure. This surgery involves moving the upper jaw (maxilla) and lower jaw (mandible) to an anatomically correct position, allowing for a good occlusion (bite), opening of the airway, and facial symmetry.

Patients who require orthognathic surgery typically exhibit a bad bite (malocclusion), facial asymmetry, or have moderate - to - severe sleep apnea. A minor malocclusion can be corrected with simple orthodontics, but some patients have a skeletal deformity of the jaw(s) that requires a combination of orthodontic treatment and surgery.

The treatment sequence usually begins with an evaluation by an orthodontist and an oral and maxillofacial surgeon. This evaluation includes x - rays, models of the dentition, photographs, facial measurements, and a complete analysis of the data to come up with a problem list and a proposed treatment plan. The team at Mount Sinai uses the most advanced 3D x - rays and computer - assisted technology for treatment planning.

The virtual surgical planning (VSP) process is an important part of orthognathic surgery. It begins with pre - operative orthodontic therapy, which can take 12 to 18 months. When the patient is ready for surgery, a complete workup is performed with the use of cone - beam 3D CT scan and 3D photo morphometry, allowing for virtual surgical planning. VSP enables the surgeon to perform or “rehearse” the surgery in a virtual environment, predict the outcome of the procedure, and design and fabricate surgical guides using 3D printers.

After the orthognathic procedure, which is performed under general anesthesia with the braces in place, internal fixation devices (small titanium screws and plates) are used to connect the repositioned segments to the jaws. Patients usually stay in the hospital for approximately 1 to 2 days. Following the procedure, training elastics are used to help retrain the patients to close into their new bites, and the patient's diet is limited to a liquid or non - chew diet for four weeks to allow for undisturbed healing of the osteotomies. The post - operative orthodontic phase, which starts 6 to 8 weeks after the surgical procedure, can last from 3 to 6 months and helps ensure long - term stability of the dentition and repositioned bone.

Management of Mandibular Fractures

When unclear mandibular margins are caused by fractures, proper management is crucial. There are two principal management procedures for condylar fractures: conservative treatment and surgical treatment. Conservative treatment is described as safe, non - invasive, easy, and low - cost, but it can have complications such as poor oral hygiene, gingivitis, facial deformity, TMJ dysfunction, and even TMJ ankylosis.

Surgical treatment, on the other hand, can provide better functional and morphological outcomes because it facilitates anatomic reduction, rigid internal fixation, and faster functional restoration. However, it also has disadvantages such as high cost, scar formation, intraoperative haemorrhage, and facial nerve injury. In recent years, with the implementation of new technology and improved understanding of fracture management, most complications of surgical treatment have been diminished and even avoided.

The surgical management of mandibular condylar fractures involves several key points:

1. Virtual evaluation of condylar fracture: Computer - assisted preoperative simulation, known as virtual surgical planning (VSP), is used. VSP enables analysis of the fracture site from different aspects, allowing the surgeon to predict reduction and fixation of the fragment or stump. It can shorten the operating time, enhance precise reduction, and improve the accuracy of hardware placement.
2. Suitable surgical approach: A well - chosen surgical approach is crucial to avoid complications such as facial nerve injuries and massive bleeding. The preauricular approach is commonly preferred for condylar head and neck fractures, while the retromandibular approach provides excellent visualisation of the neck and base of the condyle. Modified approaches, such as the supra temporalis approach and the minor parotid anterior approach, have been developed to reduce the risk of complications.
3. Good reduction: Detailed knowledge of the anatomy and position of the fracture, along with proper manipulation, allows for more ideal anatomic reduction. Intraoperative 3D C - arm cone - beam computed tomography and navigation - based surgical techniques can help in achieving accurate reduction. Guided templates can also be used to assist in the reduction of the fractured portion, but their use has some limitations.
4. Stable internal fixation: After successful reduction, the fractured portion must be stabilised and fixed. Titanium plates and screws are commonly used. For the condylar neck and base, two four - hole mini plates or geometric condylar plates may be used. Condylar head fractures are often fixated with two screws. Resorbable screws and plates have also been introduced, but their use has some drawbacks.
5. Repair of the articular disc: Successful management of condylar fractures requires restoration of the pre - traumatic anatomic reduction of the articular disc. Articular disc displacement commonly occurs after a condylar fracture, and if not repaired, it can lead to TMJ disorders and ankylosis. The disc can be reduced to its anatomical position, and if damaged, it can be replaced with suitable interpositional material such as a temporalis flap.
6. Restoration of mandibular arch width: A condylar fracture can occur along with other mandibular body fractures, leading to an increased arch width. To restore the arch width, the displaced condyle must be returned to its anatomic position. This can be accomplished by applying pressure on the gonial angle and using plates over the fractured area. In some cases, a reconstruction plate may be chosen to provide adequate stability.

Pre - and Post - operative Care in New York City Hospitals

Pre - operative Care

In hospitals in New York City, pre - operative care for patients with unclear mandibular margins is essential. For dental implant procedures, patients need to have a comprehensive oral examination, including X - rays and CT scans, to determine the bone quality and quantity. They also need to receive proper oral hygiene instructions to reduce the risk of infection. Contraindications such as poor oral hygiene, diabetes, and smoking need to be addressed before the procedure.

In the case of orthognathic surgery, patients go through a detailed evaluation process. The orthodontist and oral and maxillofacial surgeon work together to create a treatment plan. The patient is informed about the surgical procedure, possible risks, and expected outcomes. Pre - operative orthodontic treatment is often required to level and align the teeth over the maxillary and mandibular bony arches.

For patients with mandibular fractures, pre - operative care includes assessing the patient's general condition, monitoring breathing, airway, and circulation, and providing tetanus prophylaxis if needed. The fracture is carefully evaluated to determine the most appropriate treatment approach.

Post - operative Care

After dental implant placement, patients need to follow a strict oral hygiene regimen. They are instructed to avoid chewing on hard foods for a certain period and to take prescribed medications such as antibiotics and painkillers. Regular follow - up appointments are scheduled to monitor the healing process and the stability of the implant.

Following orthognathic surgery, patients have specific post - operative instructions. They are advised to keep the surgical area clean, use prescribed mouth rinses, and follow a soft or liquid diet. Training elastics are used to help with the adjustment of the bite. The orthodontist and oral and maxillofacial surgeon closely monitor the patient's progress during the post - operative orthodontic phase.

For patients who have undergone surgery for mandibular fractures, post - operative care includes managing pain, preventing infection, and promoting healing. Physical therapy may be recommended to restore normal mandibular movement. The patient's diet is adjusted according to the type of fracture and the surgical procedure, and they are monitored for any signs of complications such as malocclusion or facial nerve damage.

Challenges Faced by New York City Hospitals

New York City hospitals encounter several challenges in improving unclear mandibular margins. One of the main challenges is the high cost associated with some of the procedures, such as orthognathic surgery and dental implants. This can limit access to treatment for some patients, especially those without adequate insurance coverage.

Another challenge is the complexity of some cases. Mandibular fractures, especially those involving the condyle, can be difficult to manage due to the presence of complex anatomical structures in the area. Surgeons need to have a high level of skill and experience to perform these procedures safely and effectively.

Patient compliance is also a significant issue. Inadequate pre - and post - operative care, non - adherence to diet restrictions, and poor oral hygiene can lead to complications and poor treatment outcomes. Hospitals need to invest in patient education to improve compliance.

Conclusion

In conclusion, hospitals in New York City have several options at their disposal to improve unclear mandibular margins. Dental implants, orthognathic surgery, and appropriate management of mandibular fractures can all contribute to better oral health and function for patients. However, these procedures require careful pre - operative evaluation, skilled surgical techniques, and comprehensive post - operative care. By addressing the challenges faced, such as cost, complexity, and patient compliance, hospitals can improve the outcomes of treatment for patients with unclear mandibular margins.

If you or someone you know is dealing with unclear mandibular margins, it is recommended to consult with a dental or oral - maxillofacial professional in New York City. They can provide a thorough evaluation and recommend the most suitable treatment option based on your specific condition. Share this article with others who may benefit from this information to spread awareness about the available treatment options.