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Please cite this article in press as: Snll J, et al. Impairment ofwound healing after operative treatment ofmandibular fractures, and the

influence ofdexamethasone. BrJOral Maxillofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.08.015

ARTICLE IN PRESSYBJOM-4097; No.of Pages5

British Journal of Oral and Maxillofacial Surgery xxx (2013) xxxxxx

Available online at www.sciencedirect.com

Impairment ofwound healing after operative treatment ofmandibular fractures, and the influence ofdexamethasone

Johanna Snll a,, Kormi Eeva a, Lindqvist Christian a, Suominen Anna Liisa b,c,d,Mesimki Karri a, Trnwall Jyrki a, Thorn Hanna a

a Department of Oral and Maxillofacial Surgery, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finlandb University of Eastern Finland, Institute of Dentistry, Kuopio, Finlandc Department of Oral and Maxillofacial Surgery, Kuopio University Hospital, Kuopio, Finlandd Department of Environmental Health, National Institute for Health and Welfare, Kuopio, Finland

Accepted 29 August 2013

Abstract

Our aim was to clarify the incidence ofimpaired wound healing after open reduction and ostheosynthesis ofmandibular fractures, and to find

out whether the use ofdexamethasoneduring the operation increased the risk. Patients were drawn from a larger group ofhealthy adult dentate

patients who had participated in a single-blind, randomised study, the aim ofwhich was to clarify the benefits ofoperative dexamethasoneafter

treatment offacial fractures. The present analysis comprised 41 patients who had had open reduction and fixation ofmandibular fractures with

titanium miniplates and monocortical screws through one or 2 intraoral approaches. The outcome variable was impaired healing ofthe wound.

The primary predictive variable was the perioperative use ofdexamethasone; other potential predictive variables were age, sex, smoking habit,

type offracture, delay in treatment, and duration ofoperation. Wound healing was impaired in 13/41 patients (32%) (13/53 ofall fractures).

The incidence among patients who were given dexamethasone and those who were not did not differ significantly. Only age over 25 was

significantly associated with delayed healing (p= 0.02). The use ofdexamethasone 30 mg perioperatively did not significantly increase theriskofimpaired wound healing in healthy patients with clinically uninfected mandibular fractures fixed with titanium miniplates through an

intraoral approach. Older age is a significant predictor ofimpaired healing, which emphasises the importance ofthorough anti-infective care

in these patients during and after the operation.

2013 The British Association ofOral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Mandibular; Fracture; Glucocorticoid; Dexamethasone; Wound; Healing

Introduction

Glucocorticoids have proved to be effective in reduc-

ing postoperative nausea, pain, and oedema after various

procedures.13 Their perioperative use in association with

facial operations in general, and operations for maxillo-

facial fractures in particular, is therefore common and

widespread. However, glucocorticoids suppress the immune

Corresponding author. Tel.: +358 053621191.

E-mail address:[email protected] (J. Snll).

system through various mechanisms,4 including processes

that are essential in wound healing.5 It can therefore be

assumed that the use of perioperative dexamethasone mayincrease the riskofdifferent types ofimpaired wound healing.

A study ofthe adverse effects ofglucocorticoids on wound

healing in patients who had open reduction and osteosyn-

thesis of facial fractures showed no significant difference

in wound healing between patients who had been given

perioperative glucocorticoids and those who had not.6 An

intraoral approach remained the only significant predictor.

The study mentioned was retrospective, however, and com-

prised patients with various types offractures having different

0266-4356/$ see front matter 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

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influence ofdexamethasone. BrJOralMaxillofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.08.015


2 J. Snll et al. / British Journal of Oral and Maxillofacial Surgery xxx (2013) xxxxxx

procedures and being given various regimens of glucocor-

ticoids. The question of whether steroids had an adverse

effect on wound healing in patients treated for facial fractures,

therefore, requires further evaluation.

The aims ofthe present study were to clarify the incidence

of impaired healing after open reduction and ostheosynthe-

sis ofa mandibular fracture through an intraoral approach,and to find out whether the operative use ofdexamethasone

increases the risk.

Patients and methods

Design of the study

Patients were drawn from a larger group of healthy den-

tate patients aged 18 years or more who had participated

in a single-blind, randomised study that aimed to clarify

the effects of dexamethasone on pain, oedema, and nau-

sea after open reduction and fixation offacial fractures. Weexcluded patients with infected fractures; histories of liver

or kidney dysfunction, peptic ulcer, or psychosis from the

use ofsteroids; pregnancy; breastfeeding; or allergy to any

constituent ofthe dexamethasone preparation used.

For each type of facial fracture, patients were randomly

assigned to one of two groups. The patients in the study

group were given dexamethasone (Oradexon) 10 mg intra-

venously during induction of anaesthesia and an additional

10mg intramuscularly every 8 h for 16 h, making a total

dose of30 mg. The control patients were given no steroids.

All patients were given antibiotics until the 7th10th post-

operative day, starting with 3 doses of cefuroxime 1.5 gintravenously in the ward during the first 24 h postoperatively.

This was followed by 3 doses of cephalexin 500 mg orally.

Patients with allergies were given 4 doses ofclindamycin by

corresponding routes.

One examiner (JS or EK) followed patients up one day, 2

days, one week, one month, 3 months, and 6 months post-

operatively. Patients were followed up for surgical reasons

as needed. In addition, all patients had routine radiological

investigation with panoramic imaging immediately, and one

month, 3 months, and 6 months postoperatively.

Inclusion criteria

Patients included in the analysis had one or 2 fractures in

dentate areas of the mandible and had had open reduc-

tion and fixation with titanium miniplates. Types offracture

included: one single fracture in the angle, one single

fracture in the body, one single fracture of the symph-

ysis/parasymphysis, or a double mandibular fracture (for

example, angle + body, angle + symphyseal/parasymphyseal

fracture). All fractures were fixed through an intraoral

approach with the aid of2.0 mm miniplates and non-locking

monocortical screws. We did not use a transbuccal approach.

Symphyseal/parasymphyseal fractures were fixed with 2

miniplates, and fractures in the mandibular body and angle

were fixed with one miniplate according to the technique

described by Champy and Lodde.7 A postoperativefollow-up

period of30 days was required for the patient to be included

in the analysis.

Study variables

The outcome variable was impaired wound healing, the pres-

ence of which was established when any aberrant wound

healing, or signs of infection of the wound, developed. The

primary predictive variable was the perioperative use ofdexa-

methasone. Other predictivevariablesincluded in the analysis

were age, sex, smoking habit, type offracture, delay oftreat-

ment, and duration ofoperation.

Statistical analysis

The statistical significance of associations between the

impairment of wound healing and the perioperative use ofdexamethasone, sex, smoking habit, and fracture type were

evaluated using the chi square test. Because of the skewed

distributions for age, delay in treatment, and duration ofoper-

ation, we used Wilcoxon two sample tests to evaluate the

significance between these variables and the impairment of

wound healing.

Ethical approval

The Ethics Committee of the Department of Surgery and

the Internal Review Board ofthe Division ofMusculoskele-

tal Surgery, Helsinki University Central Hospital, Finland,approved the study (Dno 33/E6/06).

Results

Ofthe patients recruited into the initial study, 49 fulfilled the

inclusion criteria for the present analysis; ofthese, 4 refused

to participate. Ofthe remaining 45 patients, 4 were excluded:

one because he attended no follow-up appointments, one

because he required an additional operation as the reduction

of the fracture was unsatisfactory, and 2 because they failed

to complete all the doses. Forty-one patients were therefore

followed up for at least a month.

The mean follow-up period was 9 months (range 123).

The patients descriptive statistics are shown in Table 1.

In 2 patients the wound broke down sufficiently to neces-

sitate removal of the osteosynthesis material (Fig. 1). In 2

patients pus was seen in the gingival pocket of the tooth in

the fracture line on the 41st and 86th postoperative days,

respectively. One of these wounds healed with antibiotics

taken orally and root canal treatment. The other patient

required removal of the osteosynthesis material and extrac-

tion ofthe lower third molar 15 weeks postoperatively. In

2 other patients secretion ofpus and a fistula in the surgical
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J. Snll et al. / British Journal of Oral and Maxillofacial Surgery xxx (2013) xxxxxx 3

Table 1

Details of thepatients(n = 41). Data arenumber (%)unless otherwisestated.

Variable No of patients

Sex

Male 40 (98)

Mean (range) age (years) 28 (1851)

Smokers 27 (66)

Site of fracture

Angle 15 (37)

Body 2 (5)

Symphysis/parasymphysis 12 (29)

Angle + body 2 (5)

Angle + symphysis/parasymphysis 10 (24)

Mean (range) delay in treatment (days) 2 (05)

Delay (days)

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influence ofdexamethasone. BrJOralMaxillofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.08.015


4 J. Snll et al. / British Journal of Oral and Maxillofacial Surgery xxx (2013) xxxxxx

Discussion

We aimed to clarify the incidence of impaired wound

healing after open reduction and osteosynthesis ofmandibu-

lar fractures through an intraoral approach, and find out

whether the perioperative use of dexamethasone increased

it. Wound healing was impaired in 13/41 (32%) of patients

and in 13/53 (25%) of fractures. We found no significant

difference in the incidence between patients given dexameth-

asone and those who were not. Only age was significantly

associated with impaired wound healing in that the older the

patient wasthe more likely were they to have impaired healing

(p= 0.02).

Published papers have shown conflicting results about

the influence of perioperative glucocorticoids on postop-

erative complications. A study by Percival et al. showed

that patients with postoperative infections (including local

infections at the operative sites as well as generalised infec-

tions) were more likely to have been given dexamethasoneintraoperatively and less likely to have been given peri-

operative antibiotic prophylaxis than those who had no

infections.8 The authors concluded that the intraoperative

administration of dexamethasone for anti-emetic purposes

may confer an increased risk for postoperative infection.

The operations in the analysis included orthopaedic, tho-

racic, neurosurgical, ENT, vascular, plastic, breast, urology,

colonic, and gastroenterological procedures. Another study

that focussed on gynaecological surgery showed contradic-

tory results, in that there was no evidence of increased risk

of surgical infections after a single dose of dexamethasone

48mg.9

The oral area in general and the intraoral surgical approach

in particular offer advantageous circumstances for bacterial

infections. The meta-analysis by Dan et al., however, showed

that giving glucocorticoids during oral surgery did not sig-

nificantly increase the riskofinfection.3

Previously we arrived at the same result when we clar-

ified retrospectively whether perioperative glucocorticoids

are associated with impaired wound healing in patients being

treated for facial fractures: we found no significant difference

in the incidence ofimpaired wound healing between patients

who were given perioperative glucocorticoids and those who

were not.6

The results of the present study confirm these findings.

The perioperative use of dexamethasone 30 mg does not

significantly increase the risk of impaired wound healing

in clinically uninfected mandibular fractures being treated

surgically through an intraoral approach. One should note,

however, that all the patients in this study were healthy

and had no medical predisposition for infections such as

autoimmune disease or taking immunosuppressive drugs.

The potential effects ofglucocorticoids on the immune sys-

tem call for careful selection of patients, and a thorough

history is essential to identify possible contraindications to

their use.

Our only significant correlation was between impairment

of healing and age. Previous studies have shown that older

patients are more likely to have postoperative infections

in association with a mandibular fracture.10,11 Pre-existing

medical conditionsand drugs that potentially increase the risk

of postoperative inflammatory complications are more com-

mon among people over the age of 25 and may explain theresults. The present study, however, included no patients with

chronic conditions or taking long-term drugs, and confirms

that increasing age is an independent predictor ofinfections.

Wound healing was impaired in 13/53 (25%) of all

fractures. There was more of an association with angle

fractures (33%) than those of the body (25%) or symph-

ysis/parasymphysis (14%), but not a significant one. These

rates are clearly higher than those previously reported in the

USA. Ellis and Walker reported 25% in 69 angle fractures

that were treated with two non-compression miniplates, with

a wound dehiscence in one fracture and postoperative infec-

tions in 16.12 Ellis also reported 9% in 265 fractures of the

body/symphysis that were treated with two miniplates, 16wounds dehisced and 7 developed postoperative infections.13

In the present study the corresponding rate of infection in

fractures of the symphysis, parasymphysis, or body 15%.

Obviously several local and patient-related factors influence

the rate of impairment and explain the differences in the

results. Nevertheless, the results ofthe present study as well

of those of the above-mentioned studies indicate that frac-

tures ofthe mandibular angle are particularly susceptible to

postoperative complications.

Because in the present study impairment of healing was

established by 93 days or fewer, a follow-up period of 3

months seems sufficient to identify impaired wound healingand infection at the surgical site. One should note, however,

that 3 of the patients not diagnosed with impaired healing

were followed-up for fewer than 3 months (30, 40, and 42

days, respectively); one of these had been given dexameth-

asone. Although the wounds healed uneventfully in all 3

patients by the time of the final examination, some patients

withimpairmentsmay have been overlooked.A further multi-

centre studywith a larger sample would provide more reliable

conclusions about the drawbacks and benefits ofdexameth-

asone in the treatment offacial injuries.

In summary, the use ofdexamethasone 30 mg periopera-

tively was not significantly associated with an increased risk

of impaired healing in healthy patients with clinically unin-

fected mandibular fractures fixed with titanium miniplates

through an intraoral approach. Age over 25 was the only

significant predictor of impairment, which emphasises the

importance of thorough anti-infective care in these patients

during and after operation.

Conflict ofinterest statement

The authors declare that they have no conflict ofinterest.
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J. Snll et al. / British Journal of Oral and Maxillofacial Surgery xxx (2013) xxxxxx 5

Ethical approval

The Ethics Committee of the Department of Surgery and

the Internal Review Board ofthe Division ofMusculoskele-

tal Surgery, Helsinki University Central Hospital, Finland,

approved the study (Dno 33/E6/06).

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