Journal of Oral and Maxillofacial Surgery

Let's Not Skew Ourselves

Thomas B. Dodson — 2012-02-01

This above all: to thine own self be true, And it must follow, as the night the day, Thou canst not then be false to any man. —William Shakespeare, Hamlet One of my more humbling academic experiences was a required class in economics during graduate school. I confess having little success thinking like an economist, a point perhaps explaining the draw of an academic career. Over the years, however, I have found that the broad strokes of economic concepts—despite my ignorance—often resonate with my circumstances.

Is Clonidine an Adequate Alternative to Epinephrine as a Vasoconstrictor in Patients With Hypertension?

Pavan M. Patil, Seema P. Patil — 2011-09-22

Purpose: To evaluate the safety and efficacy of an admixture of lidocaine with clonidine with regard to the anesthetic abilities, hemodynamic parameters, and postoperative pain control and to compare the results with those obtained with a lidocaine-epinephrine solution. Materials and Methods: A total of 50 patients with poorly controlled, moderate hypertension (American Society of Anesthesiologists class II) who presented for uncomplicated upper third molar extraction were included in a double-blind study. The time of onset of action, duration, and intensity of anesthesia and the vasoconstrictor properties were evaluated. The hemodynamic changes (ie, systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, ST-segment depression of 1 mm or greater, and cardiac arrhythmias) were recorded. The presence of postoperative pain and analgesic requirements were also compared. The results were analyzed using an unpaired, type sample equal-variance t test with the Bonferroni correction. Results: Of the 50 patients with hypertension (American Society of Anesthesiologists class II), 25 received 2 mL of 2% lidocaine with clonidine (15 μg/mL) and 25 received lidocaine with epinephrine (12.5 μg/mL). There were no significant differences between the 2 agents with regard to the time of onset of action, duration or intensity of anesthesia, or the vasoconstrictor properties. The clonidine group showed better hemodynamic parameters compared with the epinephrine group. The clonidine group showed significantly lesser postoperative pain and, therefore, had lesser analgesic consumption. Conclusions: Clonidine could be a useful and safe alternative to epinephrine for intraoral block anesthesia with lidocaine in patients with hypertension and American Society of Anesthesiologists class II.

Verification of Nerve Integrity After Surgical Intervention Using Quantitative Sensory Testing

2011-08-01

Purpose: The aim of this study was to apply a standardized Quantitative Sensory Testing (QST) approach in patients to investigate whether oral surgery can lead to sensory changes, even if the patients do not report any sensory disturbances. Furthermore, this study determines the degree and duration of possible neuronal hyperexcitability due to local inflammatory trauma after oral surgery. Patients and Methods: Orofacial sensory functions were investigated by psychophysical means in 60 patients (30 male, 30 female) in innervation areas of infraorbital nerves, mental nerves and lingual nerves after different interventions in oral surgery. The patients were tested 1 week, 4 weeks, 7 weeks, and 10 weeks postoperatively. As controls for bilateral sensory changes after unilateral surgery, tests were additionally performed in 20 volunteers who did not have any dental restorations. Results: No differences were found between the control group and the control side of the patients. Although not 1 of the patients reported paresthesia or other sensory changes postoperatively, QST detected significant differences between the control and the test side in the mental and lingual regions. Test sides were significantly less sensitive for thermal parameters (cold, warm, and heat). No differences were found in the infraorbital region. Patients showed significantly decreased pain pressure thresholds on the operated side. QST monitored recovery over time in all patients. Conclusions: The results show that oral surgery can lead to sensory deficits in the mental and lingual region, even if the patients do not notice any sensory disturbances. The applied QST battery is a useful tool to investigate trigeminal nerve function in the early postoperative period. In light of the increasing forensic implication, this tool can serve to objectify clinical findings.

Prevalence and Management of Fourth Molars: A Retrospective Study and Literature Review

Khurram M. Shahzad, Lawrence E. Roth — 2011-08-01

Purpose: To evaluate the prevalence of fourth molars and determine if there are differences in occurrence with respect to gender, race, laterality, and site. Patients and Methods: The charts and panoramic radiographs of all patients referred for third molar consultation between November 2008 and October 2010 at Misawa, US Air Base, Japan were reviewed and data collected included age, gender, and race. Inclusion criteria were minimum age of 18 years and no history of prior third molar surgery. If fourth molars were present, their number, location, size, and shape were noted. Patients with fourth molars were compared to patients without fourth molars with respect to gender and race. Percentages were calculated for laterality and site of occurrence as well. If differences were observed in these parameters, the χ2 test was used to evaluate if the observed differences were statistically significant. Results: Four hundred nine patients met the inclusion criteria and their charts and panoramic radiographs were reviewed. Fourth molars were observed in 2.2% of the patients. Their prevalence was slightly higher in males (2.2%) than in females (2.1%). They were notably more common in black patients (6.4%) than in whites (0.9%) (P < .005) and they presented more often in the maxilla (78%) than in the mandible (22%) but this difference was not statistically significant (P < .09). Most patients (55%) with fourth molars had them unilaterally. The maxillary fourth molars were typically peg-shaped and small, while the mandibular ones resembled miniature mandibular third molars. Conclusions: The prevalence of fourth molars in this population is 2%. They appear to be more common in black patients and tend to occur mostly in the maxilla unilaterally. When present, the decision to remove these supernumerary teeth should be based on a risk/benefit analysis similar to that of third molars.

Iatrogenic Displacement of Lower Third Molar Roots Into the Sublingual Space: Report of 6 Cases

Lluís Aznar-Arasa, Rui Figueiredo, Cosme Gay-Escoda — 2012-02-01

Purpose: To describe the clinical characteristics of patients who have had sublingual displacement of a mandibular third molar root, to identify potential risk factors, and to provide the clinician with information on how to prevent and treat this complication. Patients and Methods: A retrospective analysis was performed of a series of 6 patients who underwent third molar removal with accidental displacement of a root into the sublingual space. All patients were attended at the Department of Oral Surgery, Faculty of Dentistry, University of Barcelona (Spain) from 2000 through 2010. Results: Four patients were men, and the mean age was 38.2 ± 11.3 years. In 1 case, the fragment was removed immediately after the complication, in the same surgical procedure. In 4 cases (66.7%), the displaced root remained asymptomatic (mean follow-up, 25.5 mo), and only 1 patient presented symptoms (swelling and pain in the sublingual region). A second surgical procedure using an intraoral approach was used to extract the displaced fragment in 2 patients. These 2 cases presented transitory nerve impairment of the lingual and inferior alveolar nerves, respectively. Conclusions: Accidental displacement of a lower third molar root into the sublingual space is an uncommon complication. When the fragments are small, surgical removal of the displaced roots seems to be unnecessary, because patients usually remain symptom free. When surgery is needed, a considerable incidence of complications should be expected.

Temporomandibular Custom Hemijoint Replacement Prosthesis: Prospective Clinical and Kinematic Study

2011-08-19

Purpose: To evaluate the clinical and functional outcomes of a custom temporomandibular hemijoint fossa/eminence implant prosthesis. Materials and Methods: This prospective cohort study enrolled patients with osteoarthritis of the temporomandibular joint. The primary study variables were pain experience, pain intensity, chewing ability, jaw opening, joint noise, and overall satisfaction of the surgical outcome at 3, 6, and 13 months after surgery. Pre- and postsurgical kinematic analyses measured maximum incisal opening, operated and unoperated condyle translations, and mandibular body axis rotation using mandibular kinematic data combined with patient-specific computed tomographic data. The primary analysis of interest concerned preoperative versus postoperative changes. Results: The study sample was composed of 36 subjects (mean age, 46 years; 94% female; 40 joints). There were statistically significant improvements between pre- and postoperative measurements for each study variable. The kinematic data documented preservation or an increase of bilateral condylar motion, mandibular axis rotation, and mandibular incisor motion. Conclusions: Temporomandibular joint hemiarthroplasty with a custom metal fossa/eminence prosthesis provides satisfactory clinical and functional outcomes when used for advanced osteoarthritis in patients with focal joint pain secondary to computed tomographically documented joint pathology.

Comparison of Current Perception Threshold Electrical Testing to Clinical Sensory Testing for Lingual Nerve Injuries

Vincent B. Ziccardi, Joel Dragoo, Eli Eliav, Rafael Benoliel — 2011-11-14

Purpose: We performed a retrospective study of lingual nerve injury assessment comparing the techniques of current perception threshold testing versus clinical sensory testing. Patients and Methods: We designed and implemented a cross-sectional study and enrolled a patient sample with lingual nerve injuries presenting for treatment to the principal investigator. The predictor variables were clinical sensory testing modalities (ie, temperature, nocioception, vibration, 2-point discrimination, brush stroke, and von Frey monofilament perception). The primary outcome variable was the electrical current perception thresholds of the tongue dorsum (neurometer measurements at 5, 250, and 2,000 Hz). Comparisons were established with the ipsilateral affected and contralateral unaffected lingual nerve distributions. The associations between the clinical sensory testing and current perception threshold measurements were assessed using correlation coefficients, with the level of statistical significance set at P < .05. Results: A total of 40 patients (13 males and 27 females) were included in the present study. The average age of these patients was 34 years (range 13 to 66). Significant correlations were observed between the electrical stimulation thresholds at 2,000 Hz and the 2-point discrimination, reaction to brushing, reaction to vibration, and von Frey fiber thresholds, between the electrical stimulation thresholds at 250 Hz to the nociceptive and thermal thresholds, and between the electrical stimulation thresholds at 5 Hz to thermal stimuli. Conclusions: The significant correlations observed in the present study indicate that current perception threshold can be a complementary or alternative tool in the assessment and evaluation of lingual nerve injuries.

Telemedicine as an Effective Tool for the Management of Temporomandibular Joint Disorders

2011-08-01

Purpose: To evaluate the effectiveness of a store-and-forward telemedicine system (SFTMS) as an optimal method for the selection, diagnosis and treatment of patients with TMJ disorders (TMJD) referred from primary care sites to the Maxillofacial Surgery Unit (hospital-based). Materials and Methods: A multicenter, analytical, quasi-experimental, non-randomized clinical study of a SFTMS aimed towards the management of patients with TMJD was conducted at the Oral and Maxillofacial Surgery Unit of the Virgen Macarena University Hospital (Seville, Spain) and 10 primary care areas of the North area of Seville located between 15 and 180 km from the hospital. The study was carried out between January 2008 and February 2010 including a non-random sample consisting of all patients with TMJD treated at primary care sites during the study period. We describe the development and effectiveness of this method based on the rates of diagnosis of myofascial syndrome and/or internal deragement Wilkes Stages I-II-III, internal deragement Wilkes Stages IV-V, other arthropathies, resolved teleconsultations, second teleconsultations, referrals to hospital, mean treatment delay, lost hours working/patient and complaints. The same variables were also described for the TMJD conventional consultation system at hospital (standard system). Descriptive statistics (frequency tables, means and medians, and dispersion measures), T-Student test was used to compare the differences in the average quantitative variables (time) and Chi2 test was used to compare the differences in the average qualitative variables. Results: Over a 24-month period, 710 patients with TMJD were assisted at hospital by conventional consultation from 1-1-2008 to 2-25-2010, of which 587 (82.7%) were women and 123 (17.3%) were men with a mean age of 41.08 years. The mean time elapsed until treatment onset was 78.6 days, with a mean cost of 32 lost working hours per patient. In this period, 342 patients with TMJD were assisted by teleconsultation, of which 276 (80.7%) were women and 66 (19.2%) were men with a mean age of 38.3 years. Only 35 (10%) patients presented some other TMJ pathology that required maxillofacial surgery. The remaining 307 (89.7%) received non-surgical treatment in the primary care center (high resolutive consultations) in a mean time of 2.3 days (p<0.05), and a mean cost of 16 lost working hours/patient (p<0.05). Conclusions: Telemedicine allows a correct diagnosis and an adequate treatment for the majority of TMJD from primary care sites and shortens the delay in treatment onset, preventing displacement and unnecessary costs for these patients.

Bilateral Temporomandibular Joint Dislocation With Locked Mandibular Impaction

2012-02-01

Bilateral anterior temporomandibular joint dislocation is very rare, with only 2 reported cases published. In the present report, we describe a healthy 25-year-old man from Haida Gwaii, in British Columbia, Canada, who was transferred to our tertiary trauma center with life-threatening complications of a bilateral anterior temporomandibular joint dislocation with locked mandibular impaction.

Assessing Validity of Actual Tooth Height and Width From Cone Beam Images of Cadavers With Subsequent Dissection to Aid Oral Surgery

Brion Benninger, Andrew Peterson, Valane Cook — 2011-06-20

Purpose: Cone-beam computed technology (CBCT) is a relatively new medium for maxillofacial conditions. Developed in 1998, commercial cone beam technology has been commonly used since 2000. CBCT offers less radiation than computed tomography (CT) in 3D image construction. With the meteoric rise in the number of dental implant surgeries, CBCT could become a common machine in dental offices. The objective of this study is to validate the accuracy of CBCT tooth measurements. Materials: Twelve embalmed cadavers had a complete CBCT of the head and neck region. Ninety-six teeth (8 per cadaver) were extracted in total, but only 69 were collected and measured. CEN-TECH electronic calipers were used to measure the extracted teeth. iCAT measurements were used for imaged teeth. Methods: A literature search was conducted on the validity and use of CBCT regarding tooth measurements for implant surgery. Extracted teeth were measured in the vertical, facial to lingual, and mesial to distal dimensions. Exclusion factors included crown or root fracture damage during extraction. Results: A literature search revealed studies that validated bone measurements using 14 different location points on the maxilla and 17 anatomical landmarks on the skull. Both studies validated bone measurements on CBCT. However, no studies were identified measuring teeth lengths for implant surgery. Three, two-tailed, paired t-test compared the iCAT image measurements to the extracted teeth measurements for each dimension. There was no statistical significance for each dimension. Conclusion: This study suggests using iCAT measurements on teeth from CBCT imaging would reflect the actual tooth length and could be beneficial for implant surgery.

Does Implant Staging Choice Affect Crestal Bone Loss?

2011-12-15

Purpose: The purpose of the present study was to compare the crestal bone loss around implants placed according to either a 1-stage or 2-stage implant installation procedure using a digital subtraction radiography technique. Materials and Methods: In the present randomized clinical trial, screw-shaped tapered implants were inserted in the posterior mandible of patients needing fixed partial dentures. In each edentulous area, according to the randomization table, 1 implant was inserted using a 1-stage procedure (group 1) and 1 was placed using a 2-stage approach (group 2). The implants were temporized with the relined denture after 2 weeks. All implants were functionally loaded with fixed partial dentures after 3 months. Crestal bone loss (primary outcome variable) was measured using a digital subtraction radiography technique. Standardized radiovisiographs were taken after implant insertion, after fixed partial denture installation (3 months after surgery), and after 6 and 12 months of functional loading. The data were analyzed using the Wilcoxon signed ranks test (α = 0.05). Results: Eleven patients (mean age 46.9 years, 3 women and 8 men) were included in the study. A total of 34 implants were inserted, 17 using a 1-stage protocol and 17 using a 2-stage protocol. Three months after implant placement, the 2-stage implants showed significantly more crestal bone loss (0.65 ± 0.71 mm) than the 1-stage implants (0.41 ± 0.53 mm; P = .02). However, after 6 and 12 months of functional loading, both groups showed comparable changes in bone level (P > .05). Conclusions: No differences were found between 1-stage and 2-stage implant placement in crestal bone loss after 1 year of functional loading.

Evaluation of Satisfaction of Patients Rehabilitated With Zygomatic Fixtures

2011-07-25

Purpose: The aim of this study was to evaluate the satisfaction of patients rehabilitated with zygomatic fixtures and prosthesis with immediate loading. Materials and Methods: The study selected patients who were rehabilitated with zygomatic implants at the clinic of the Latin American Institute for Dental Research and Education (ILAPEO. Curitiba-PR. Brasil) between 2005 and 2009. The patients were asked to answer a control-questionnaire during their follow-up visits. Data were collected regarding the level of patient satisfaction, reason for dissatisfaction, number of post-operative clinical sessions, and the type of complication. Sixteen patients were selected: 10 females and 6 males. Results: Half of the patients were completely satisfied while the other half were satisfied with some complaints. The complaints were related to hygiene, esthetics, phonetics, and discomfort during chewing. Regarding the post-operative evaluation, 50% of the patients were attended due to the prosthesis (62.5%) and the implant (37.5%). Conclusions: The treatment with zygomatic fixtures is predictable and reliable. The patients were satisfied both with implants and prosthesis.

Multilocularity as a Radiographic Marker of the Keratocystic Odontogenic Tumor

2011-07-21

Purpose: The purpose of this study was to answer this clinical question: When a patient presents with a radiolucent lesion of the mandible presumed to be an odontogenic cystic lesion, to what extent is the radiographic finding of multilocularity predictive of a final diagnosis of keratocystic odontogenic tumor (KCOT)? Materials and Methods: The study sample was derived from the population of patients who presented to the Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital for evaluation and management of suspected mandibular lesions from January 1991 through January 2009. Subjects were eligible for study inclusion if there was a final histologic diagnosis of KCOT or dentigerous cyst. The predictor variable was radiographic appearance of the lesion and was grouped into 2 categories (unilocular or multilocular). The outcome variable was lesion type (KCOT or dentigerous cyst). Appropriate univariate, bivariate, and multivariate statistics were computed. Statistical significance was defined as P < .05. Results: The study consisted of 130 subjects. Multilocular lesions were 1.7 times more likely to be KCOTs than unilocular lesions (P = .0001). The sensitivity, specificity, and positive and negative predictive values were 0.48, 0.87, 0.86, and 0.49, respectively. In the multiple logistic regression model, a multilocular radiographic appearance was associated with a 12-fold (95% confidence interval, 3.7 to 38) increased risk of KCOT. Conclusion: The results of this study confirm the hypothesis that radiographic multilocularity is predictive of a KCOT because it is associated with a 12-fold increased risk for the diagnosis of KCOT.

Bisphosphonate-Related Osteonecrosis of Jaws in 3 Osteoporotic Patients With History of Oral Bisphosphonate Use Treated With Single Yearly Zoledronic Acid Infusion

2011-07-04

In recent years, much attention has been focused on the growing issue of bisphosphonate-related osteonecrosis of the jaws (BRONJ) in the setting of both high-dose intravenous bisphosphonates used for primary or metastatic bone-related cancer and oral bisphosphonates used in the treatment of osteoporosis.

Intraosseous Venous Malformation of the Mandible: A Review on Interdisciplinary Differences in Diagnostic Nomenclature for Vascular Anomalies in Bone and Report of a Case

Eron Aldridge, Larry L. Cunningham, T.J. Gal, Juan F. Yepes, Behruz J. Abadi — 2011-07-28

Vascular anomalies often affect the soft tissues of the maxillofacial region but are rarely found in bone. They account for fewer than 1% of all bony “tumors” and are most frequently described in the vertebral column and calvarium. The maxilla and mandible are the most commonly affected bones of the facial skeleton. Intraosseous vascular anomalies have also been described in the literature to be found within the zygoma, orbit, and condyle. Because of their ability to cause significant hemorrhage after relatively minor insults, intraosseous vascular anomalies can be life-threatening entities. Spontaneous hemorrhage is reported to have caused at least 25 deaths. Patients with intrabony vascular lesions have developed bleeding from dental cleanings and undergone biopsies and simple extractions of teeth. Some of these have resulted in severe hemorrhage, airway compromise, or exsanguination.

Cervicofacial Necrotizing Fasciitis and Steroids: Case Report and Literature Review

Matthew Murray, Jeffrey Dean, Richard Finn — 2011-06-13

Necrotizing fasciitis (NF) is a devastating disease that typically affects immunocompromised patients but can also affect healthy patients. The disease can be caused by a monomicrobial or polymicrobial infection and spreads rapidly. Monomicrobial infections are usually due to group A streptococcus and are uncommon.

Surgical Treatment for Nontuberculous Mycobacterial (NTM) Cervicofacial Lymphadenitis in Children

Jerome A.H. Lindeboom — 2011-07-11

Purpose: To compare surgical excision with surgical curettage in the treatment of nontuberculous mycobacterial (NMT) cervicofacial lymphadenitis in children. Patients and Methods: Fifty children, 22 boys and 28 girls, with a PCR- or cultured-confirmed diagnosis of cervicofacial NTM infection were included in the study. Twenty-five children were randomized to surgical excision of the involved lymph nodes, and 25 children to surgical curettage. Results: The median age of the children was 36 months (range, 14-120 months). All children had a red, fluctuating lymphadenitis, and there were no marked differences between the treatment groups with respect to mean duration of lymph node swelling before presentation, location, and the size of the lymph node swelling. Most (84%) of the involved nodes were located in the submandibular region and 6% were located in the preauricular region. Multiple locations (both preauricular and submandibular) were observed in the remaining 10%. Mycobacterium avium (74%) and Mycobacterium haemophilum (22%) were the predominant NTM species. Mean wound healing time for the excision group was 3.6 ± 1.2 weeks versus 11.4 ± 5.1 weeks for the curettage group (P ≤ .05). Postoperative transient marginal mandibular nerve weakness of the facial nerve was seen in 4 patients (16%) of the excision group. In all these patients the function of the nerve returned to normal within 12 weeks. No facial nerve problems were observed in the curettage group. Postoperative infections were not observed. Conclusions: Surgical excision leads to a quick resolution of NTM cervicofacial lymphadenitis. Curettage leads to delayed healing but might be considered as an alternative if excision of the necrotized lymph nodes is technically difficult in cases of adherence of the facial nerve branche.

Traumatic Ulcerative Granuloma With Stromal Eosinophilia: Report of a Case and Literature Review

2011-07-21

Traumatic eosinophilic granuloma with stromal eosinophilia is a rare entity that affects the oral mucosa and has a controversial etiologic pathogenesis. Histologically, these lesions are characterized by a dense and deeply infiltrative lymphoproliferation showing epitheliotropic characteristics and massive eosinophilia. Frequently, a population of mitotically active, atypical mononuclear cells can be noted. This report describes a case of traumatic eosinophilic granuloma with stromal eosinophilia in the floor of the mouth of an 88-year-old man. The phenotypic and genotypic profiles of the inflammatory infiltrate and large atypical mononuclear cells, using immunohistochemical and polymerase chain reaction-based molecular analysis, were analyzed.

Role of Early Diagnosis and Multimodal Treatment in Rhinocerebral Mucormycosis: Experience of 4 Cases

2011-06-17

Mucormycosis is an acute, uncommon opportunistic fungal infection seen primarily in patients with poorly controlled diabetes mellitus. It is a rare fungal infection but has been reported with increasing frequency in immunocompromised patients and is potentially lethal. Mucormycosis caused by order Mucorales, a ubiquitous saprophytic mold found in soil and organic matter worldwide, is a rare but invasive opportunistic fungal infection. It occurs in 2 main forms, superficial and visceral. The visceral form, which affects the head and neck region, is most commonly encountered by the oral and maxillofacial surgeon. Due to its lethal nature, it must be recognized early and treated aggressively. Appropriate management results in a cure in only about half of rhinocerebral infections. The reported survival rate is variable, ranging from 20% to 70%. Management of the condition includes early diagnosis, initiation of medical therapy, and aggressive surgical debridement, which requires teamwork by various disciplines to attain an improved and favorable prognosis.

Ectopic Thyroid Gland in the Mandible: A Case Report and Review

Yunliu Zhao, Gaochen Pu, Qian Li, Mingyi Wu — 2011-08-19

Ectopic thyroid gland (ETG) is any thyroid tissue not located in its normal cervical position, which is a rare congenital anomaly and can be seen anywhere along the route of the descending gland. It appears primarily in the cervical midline and is rarely found in other anatomic sites. Because ETG can be manifest in a variety of possible locations, the clinical appearance is different for each case; thus ETG poses difficult diagnosis and management problems. Seventy percent of patients with displaced thyroid tissue lack a cervical thyroid. Therefore it is important to consider ETG in the clinical differential diagnosis of mandibular masses to prevent iatrogenic hypothyroidism. To date, there is no report in the literature concerning ETG presenting in the mandible. The presented case represents the initial report of this condition in the literature. Our patient had ETG in the mandible, with thyroid gland tissue in the expected location in the neck. The differential diagnosis and clinical management of this rare case are also discussed.

Pigmented Villonodular Synovitis of the Temporomandibular Joint Presenting as a Middle Cranial Fossa Tumor

Yuan-Kai Liu, Jun-Yeen Chan, Chih-Ju Chang, Jing-Shan Huang — 2011-07-11

Pigmented villonodular synovitis (PVNS) is an infrequently occurring proliferative lesion arising from the synovial membranes of particular body joints, bursae, and associated tendon sheaths. This condition was first described by Jaffe et al in 1941 and has an annual incidence of 1.8 cases per 1 million individuals in the United States. PVNS is related to a family of lesions including pigmented villonodular tenosynovitis and pigmented villonodular bursitis, with the diagnosis depending on the anatomic area involved. Both nodular and diffuse forms of PVNS are currently recognized. The most common nodular patterns associated with PVNS include giant cell tumor, xanthoma, xanthogranuloma, and myeloplaxoma, with each form generally tending to affect a discrete part of the synovium. Diffuse PVNS, which typically affects the entire synovium, has been referred to as giant cell fibrohemangioma, chronic hemorrhagic villous synovitis, and benign polymorphocellular tumor. Although PVNS can occur in virtually any joint of the human body, approximately 80% of cases involve the knee, with the hip, ankle, foot, hand, elbow, and shoulder accounting for almost all other cases. To our knowledge, PVNS involvement of the temporomandibular joint (TMJ) is very uncommon, with only 45 cases reported in the literature since 1973 ().

Homo Neanderthalensis; First Documented Benign Intraosseous Tumor in Maxillofacial Skeleton

Giuseppe Colella, Salvatore Cappabianca, Giovanni Gerardi, Francesco Mallegni — 2011-07-28

This report deals with the first benign intraosseous tumor of the maxillofacial skeleton ever documented in a species of the Homo genus, to our knowledge. The lower jaw, which belonged to a representative of Homo neanderthalensis, indicated that expansive processes with bone remodeling were already present in ancient times, showing no difference with similar disease patterns found daily in modern Homo sapiens.

Giant Rhinophyma of the Nose

Mahesh Mangal, Anuja Agarwal, Harsha Jain, Anubhav Gupta — 2011-07-28

The term rhinophyma originates from the Greek rhis (nose) and phyma (growth) and is characterized by slow progressive hypertrophy of the sebaceous glands and connective tissue on the nose. It was described by Hippocrates and the ancient Arabs, and examples are found in portraiture through the ages. There are many synonyms (>30 listed by Odou and Odou) for the condition, ranging from potato nose and rum blossom to pachydermatosis and pseudo-elephantiasis of the nose. Rarely, these lesions can attain a giant size and pose a difficult management challenge.

Preoperative Evaluation of Spatial Relationship Between Inferior Alveolar Nerve and Fibro-osseous Lesion by High Resolution Magnetic Resonance Neurography on 3.0-T System: A Case Report

2012-02-01

Many imaging methods have become useful for preoperative evaluation of potential complications, but it has been difficult to predict sensory disorders caused by traumatic nerve injury during surgical procedures. This results from difficulty in simultaneous visualization of peripheral nerves as soft tissue and teeth or bone as hard tissue. We present a successful case in which an advanced magnetic resonance imaging (MRI) method provided precise estimation of the distance between lesions and helped us to determine the most appropriate surgical approach. With the use of this method, nerve injury upon removal of an impacted tooth with a fibro-osseous lesion (FOL) continuous with the inferior alveolar nerve (IAN) could be avoided. This procedure was performed with high-resolution 3-dimensional (3D) volume rendering (3DVR) magnetic resonance neurography (MRN) on a 3.0-T system.

Can an Arch Bar Replace a Second Lag Screw in Management of Anterior Mandibular Fractures?

Hany A. Emam, Mark R. Stevens — 2011-11-14

Purpose: To evaluate the efficacy of using a single lag screw combined with an arch bar in the management of anterior mandibular fractures and to compare this method with the traditional application of 2 lag screws. Materials and Methods: We designed and implemented a randomized clinical trial and enrolled a sample of patients with anterior mandibular fractures. Twenty adult male patients were randomly divided into 2 equal groups according to the number of lag screws used for fracture fixation after securing the occlusion with intermaxillary fixation. In group A, the fractures were treated using 2 lag screws. In group B, the fractures were treated using a single lag screw and an arch bar on the teeth, spanning the fracture line. Clinical and radiographic evaluations were used to evaluate the efficacy of each fixation method immediately and at 2 and 4 months postoperatively. Results: The clinical examination showed stable fixation with no mobility or infection in all cases. One patient in group A showed a slight occlusal discrepancy that was managed with occlusal adjustment. The pretraumatic occlusal relationship of all other patients was re-established. Postoperative radiographs showed properly reduced fracture segments with gradual bone healing. No significant difference was noted (P > .05) between the 2 groups in the development of postoperative complications. Conclusions: The use of 1 lag screw in conjunction with an arch bar across the fracture line is rigid and stable enough to manage anterior mandibular fractures without the need for supplemental intermaxillary fixation. The use of a single lag screw offers several advantages compared with the traditional use of 2 lag screws. These advantages include decreased cost, use of materials, healing time, and risk of associated morbidity.

Endoscope-Assisted Transoral Reduction and Internal Fixation Versus Closed Treatment of Mandibular Condylar Process Fractures—A Prospective Double-Center Study

2011-06-13

Purpose: The aim of this international AO-study was to compare the functional outcome after open versus closed treatment of mandibular condylar neck fractures. Patients and Methods: A prospective comparative study with two follow-ups (FU) at 8-12 weeks and 1 year was undertaken in two clinics, which exclusively privileged either surgical or conservative treatment due to different therapeutic agendas. Patients from clinic 1 (ENDO group) received endoscope-assisted transoral open reduction and internal fixation, whereas patients from clinic 2 (CONS group) were treated conservatively without surgery. Patients with unilateral condylar neck fractures showing one or more of the following conditions were included: displacement of the condyle with an inclination >30° and/or severe functional impairment such as malocclusion or open bite, with or without dislocation of the condylar fragment; severe pain upon palpation or movement, and/or vertical shortening of the ascending ramus. High or intracapsular condylar neck fractures were excluded. Results: 75 patients (44 CONS and 31 ENDO patients) with condylar neck fractures were included in this study. The Asymmetric Helkimo Dysfunction Score (A-HDS) was slightly lower in the CONS group than in the ENDO group at the 8-12-week FU, corresponding to better function on the short-term. At the 1-year FU, however, there were slightly better values in the ENDO group. For the Clinical Dysfunction Index (Di) and the Anamnestic Dysfunction Index (Ai), CONS patients had a better outcome than ENDO patients at the 8-12 week FU, ie, a higher proportion of ENDO patients had severe symptoms due to the operative trauma. Yet these symptoms improved by one year, finishing with a significant higher proportion of symptom-free patients in the ENDO group. In addition, these patients had better values for the Index for Occlusion and Articulation Disturbance (Oi) at both FU examinations, ie, the proportion of patients without any occlusal disturbances was significantly higher in the ENDO group. On average, the duration of postoperative maxillo-mandibular fixation (MMF) was 3 times longer for the CONS group than for the ENDO group (33 vs. 11 days). Conclusion: Both treatment options may yield acceptable results for displaced condylar neck fractures. Especially in patients with severe malocclusion directly after trauma, however, endoscope-assisted transoral open reduction and fixation seems to be the appropriate treatment for prevention of occlusal disturbances during FU.

Dental Injuries in Pediatric Patients With Facial Fractures Are Frequent and Severe

2012-02-01

Purpose: This study was carried out to identify the occurrence, type, location, and severity of dental injuries (DIs), as well as predictors for DIs, in pediatric patients with facial fractures. Materials and Methods: This study examined the files of patients aged 16 years or less who had sustained facial fractures during a 12-year period. The outcome variable was DI. The explanatory variables included gender, age, trauma mechanism, and type of facial fracture. Data analysis was carried out with the χ2 test and logistic regression analysis. Results: A total of 200 patients, 119 (59.5%) of whom were boys, met the inclusion criteria. The mean age was 12.6 years. A total of 45 patients (22.5%) had DIs. Crown fracture, the most common type of DI, occurred in 59.9% of all DIs. The most common location of crown fractures was in the premolars (37.4% of all crown fractures). Multiple DIs occurred in 71.1% of those with DIs and severe DI in 66.7%. DIs were significantly associated with motor vehicle collision (MVC) (P = .02) and mandibular fracture (P = .03). Conclusions: DIs are common in pediatric patients with facial fracture, often being both multiple and severe. In association with pediatric facial fracture, facial surgeons should be especially alert for crown fractures in the lateral parts of the jaws.

Risk Factors for Neurosensory Disturbance After Bilateral Sagittal Split Osteotomy Based on Position of Mandibular Canal and Morphology of Mandibular Angle

2011-05-09

Purpose: The aim of the present study was to evaluate the potential morphologic risk factors for postoperative neurosensory disturbance (NSD) after bilateral sagittal split osteotomy. Patients and Methods: The study subjects were 30 skeletal Class III patients (9 males and 21 females), with a mean age of 22.0 years (range, 16-39 years). All patients underwent bilateral sagittal split osteotomy for setback to correct mandibular prognathism. The bone marrow space between the outer mandibular canal and the lateral cortex of the ramus was measured on transaxial computed tomography images, and the length at the mandibular angle between the retromolar and gonion was measured on the lateral cephalograms. The NSD was tested bilaterally using discrimination to touch with the sharp head of a mechanical probe. Each patient was evaluated at 1, 3, and 6 months postoperatively. Results: The median bone marrow space was 1.96 mm (range, 0-4.5 mm), and median length of the mandibular angle was 30.93 mm (range, 23-37 mm). Neurosensory disturbance was present on 15 sides (25.0%) at 1 month postoperatively, 9 sides (15.0%) at 3 months postoperatively, and 7 sides (11.7%) at 6 months postoperatively. The difference in the incidence of NSD with a small bone marrow space and a long mandibular angle from that with a large bone marrow space and short mandibular angle was highly statistically significant (P = .006 and P < .01, respectively). Conclusions: The frequency of NSD after bilateral sagittal split osteotomy in Class III cases was dependent not only on the position of mandibular canal, but also on the length of the mandibular angle. A lateral course of the mandibular canal and a long mandibular angle appeared to result in a high risk of injury to the inferior alveolar nerve, resulting in NSD owing to a compromised splitting procedure.

Automated Continuous Mandibular Distraction Osteogenesis: Review of the Literature

Batya R. Goldwaser, Maria E. Papadaki, Leonard B. Kaban, Maria J. Troulis — 2011-06-16

Purpose: Current devices for mandibular distraction osteogenesis (DO) are complex and require significant patient or family skill during active distraction. Successful development of an automated, continuous distraction device would eliminate the need for patient participation in this process. The purpose of this study was to comprehensively review devices currently in development for continuous DO and to identify and evaluate the achieved successes and remaining problems. Materials and Methods: A PubMed search of the English language literature in October 2008 using the keywords automatic or automated or continuous or hydraulic or motor or magnetic or spring and distraction osteogenesis was performed. The search included all technical notes, animal studies, and human studies describing the use of any automated continuous distraction device for the mandible. Excluded were studies using distraction devices employing hydraulics, motors, or springs that did not distract automatically and continuously and devices used for bones other than the mandible. Results: The search returned 97 matches. Of these, 12 articles were selected as relevant to this review based on the inclusion and exclusion criteria detailed above. Eight distinct devices for automated, continuous DO were described in these reports and evaluated in this review. These included motor-driven, spring-mediated, and hydraulically powered distractors. Conclusions: The abundance of research currently underway to develop a continuous distractor highlights the clinical demand for, and usefulness, of such a device. Despite many advances and promising results, significant problems remain to be overcome before any of these devices gain widespread clinical acceptance.

Subjective Outcomes of Maxillomandibular Advancement Surgery for Treatment of Obstructive Sleep Apnea Syndrome

Reginald Goodday, Susan Bourque — 2011-07-15

Purpose: To evaluate subjective outcomes and use of continuous positive airway pressure (CPAP) after maxillomandibular advancement surgery for treatment of obstructive sleep apnea syndrome (OSAS). Patients and Methods: A self-administered questionnaire was completed pre- and postoperatively by 116 patients who underwent maxillomandibular advancement surgery for treatment of OSAS from February 2000 through September 2010. The questionnaire included the Epworth Sleepiness Scale (ESS) for assessment of daytime somnolence and questions regarding snoring, witnessed apneas, CPAP use, and overall satisfaction. Results: Preoperatively, 40% of patients were very sleepy (ESS ≥16), 32% were sleepy (ESS 10 to 16), and 28% were not sleepy (ESS ≤10). Postoperatively, only 1 patient (<1%) was very sleepy, 9% were sleepy, and 90% were not sleepy (McNemar test, P < .001). The mean ESS score for the very sleepy, sleepy, and not-sleepy groups decreased from 18.3 to 5.9, 12.9 to 4.4, and 7.3 to 4.5, respectively (P < .001). Surgery decreased snoring by 83%, witnessed apneas by 94%, and CPAP use by 96% (P < .001). The surgery was judged to be worthwhile by 89% of patients, and 95% of patients said they would recommend the treatment to other patients with OSAS. Conclusions: Maxillomandibular advancement surgery for treatment of OSAS is very effective at improving excessive daytime sleepiness, snoring, and witnessed apneas. Most patients in this study were able to discontinue the use of CPAP after surgery. Overall, patients reported the treatment to be worthwhile and would recommend it to others.

Revisiting the Supraforaminal Horizontal Oblique Osteotomy of the Mandible

Wolfram M.H. Kaduk, Fred Podmelle, Patrick J. Louis — 2011-06-20

Purpose: Today, the most common orthognathic procedure for correction of mandibular deformities is the bilateral sagittal split osteotomy, also called sagittal ramus osteotomy. Permanent injury to the mandibular nerve (V3) is one of the main complications, with a reported incidence between 5% and 30%. Orthognathic surgery using sagittal ramus osteotomy of the mandible as the procedure of choice should be re-evaluated because of the complexity and the relatively high risk of damage to the inferior alveolar nerve. Surgical techniques that allow for accurate condylar positioning with a lower risk of inferior alveolar nerve injury should be considered. The aim of this study is to present a retrospective case series using the previously described horizontal osteotomy of the mandibular rami along with modern-day technical advances that make this procedure safe, reliable, and reproducible. Materials and Methods: We performed a modified approach to the supraforaminal horizontal oblique osteotomy of the mandible with a condylar positioning device, endoscopy, and a surgical navigation system. This technique was performed in 17 consecutive patients. Postoperatively, we measured the amount of surgical movement of the mandible, monitored the mandibular nerve, and evaluated bone healing during removal of the osteosynthesis plates. Results: In all 17 treated patients there was uneventful wound healing, and no patient had permanent nerve alteration. The mean movement of the mandible was 7.48 mm (SD, 2.1 mm), with a range from 3.0 to 10.5 mm. The mean follow-up was 19 months. The main purpose of the surgical navigation was the translation of the planned osteotomy line from the computed tomography scan to the surgical site during the operation. This was performed to prevent a large gap between the bone segments at the osteotomy site. Conclusion: The supraforaminal approach with a condylar positioning device appears to be an appropriate way to prevent injury to the inferior alveolar nerve during orthognathic surgery of the mandible while maintaining centric positioning of the condyle and obtaining good bony union.

Bone Regeneration and Docking Site Healing After Bone Transport Distraction Osteogenesis in the Canine Mandible

2011-05-23

Purpose: Bone transport distraction osteogenesis provides a promising alternative to traditional grafting techniques. However, existing bone transport distraction osteogenesis devices have many limitations. The purpose of this research was to test a new device, the mandibular bone transport reconstruction plate, in an animal model with comparable mandible size to humans and to histologically and mechanically examine the regenerate bone. Materials and Methods: Eleven adult foxhounds were divided into an unreconstructed control group of 5 animals and an experimental group of 6 animals. In each animal, a 34-mm segmental defect was created in the mandible. The defect was reconstructed with a bone transport reconstruction plate. Histologic and biomechanical characteristics of the regenerate and unrepaired defect were analyzed and compared with bone on the contralateral side of the mandible after 4 weeks of consolidation. Results: The reconstructed defect was bridged with new bone, with little bone in the control defect. Regenerate density and microhardness were 22.3% and 42.6%, respectively, lower than the contralateral normal bone. Likewise, the anisotropy of the experimental group was statistically lower than in the contralateral bone. Half the experimental animals showed nonunion at the docking site. Conclusion: The device was very stable and easy to install and activate. After 1 month of consolidation, the defect was bridged with new bone, with evidence of active bone formation. Regenerate bone was less mature than the control bone. Studies are underway to identify when the regenerate properties compare with normal bone and to identify methods to augment bone union at the docking site.

Human Masseter Muscle Fiber Type Properties, Skeletal Malocclusions, and Muscle Growth Factor Expression

2011-08-08

Purpose: We identified masseter muscle fiber type property differences in subjects with dentofacial deformities. Patients and Methods: Samples of masseter muscle were collected from 139 young adults during mandibular osteotomy procedures to assess mean fiber areas and percent tissue occupancies for the 4 fiber types that comprise the muscle. Subjects were classified into 1 of 6 malocclusion groups based on the presence of a skeletal Class II or III sagittal dimension malocclusion and either a skeletal open, deep, or normal bite vertical dimension malocclusion. In a subpopulation, relative quantities of the muscle growth factors IGF-I and GDF-8 gene expression were quantified by real-time polymerase chain reaction. Results: Fiber properties were not different in the sagittal malocclusion groups, but were very different in the vertical malocclusion groups (P ≤ .0004). There were significant mean fiber area differences for type II (P ≤ .0004) and type neonatal—atrial (P = .001) fiber types and for fiber percent occupancy differences for both type I-II hybrid fibers and type II fibers (P ≤ .0004). Growth factor expression differed by gender for IGF-I (P = .02) and GDF-8 (P < .01). The ratio of IGF-I:GDF-8 expression associates with type I and II mean fiber areas. Conclusion: Fiber type properties are very closely associated with variations in vertical growth of the face, with statistical significance for overall comparisons at P ≤ .0004. An increase in masseter muscle type II fiber mean fiber areas and percent tissue occupancies is inversely related to increases in vertical facial dimension.

Bilateral Parotid Duct Obstruction After Rhytidectomies: Case Report

Louis Mandel, A. John Silver — 2011-06-20

Facelifts, aimed at improving the appearance of the lower two thirds of the face, have become common procedures in our society. A safe and successful facelift, or rhytidectomy, requires an appreciation of the anatomy of the superficial musculoaponeurotic sheath (SMAS). The SMAS represents a facial continuation of the superficial cervical fascia that extends superiorly to the malar region while inferiorly it becomes a part of the platysma. Posteriorly, the SMAS invests another fascial layer, the superficial layer of the deep cervical fascia, or parotid-masseteric fascia (PMF). The PMF, a thin fascial layer in close relation to the SMAS, covers the parotid gland, parotid duct, masseter muscle, and branches of the facial nerve as they emerge anteriorly from the parotid gland and are distributed to the facial musculature.

Corticotomy-Assisted Orthodontic Enhancement by Bone Morphogenetic Protein-2 Administration

2012-02-01

Purpose: To determine the possibility of synergistically enhancing orthodontic tooth movement (OTM) and bone formation in vivo by administering bone morphogenetic protein type 2 (BMP-2) on the tension side or in combination with corticotomy on the pressure side. Materials and Methods: The sample consisted of 56 Wistar rats that were subjected to experimental OTM for 32 days using a split-mouth design. The sample was divided into 4 groups: a control group, a corticotomy group, a BMP-2 group, and a corticotomy plus BMP-2 group. An OTM force of 10 cN was applied to each group. BMP-2 18 μL was administered locally on the tension side alone or in conjunction with corticotomy and then compared with the controls using fluorescence-based tartrate-resistant acid phosphatase staining for osteoclast counts, histologic bone resorption, and clinical OTM results. Results: Corticotomy surgery increased the OTM rate (P < .05) by more than 20%. The injection of BMP-2 alone on the tension side did not induce significant changes in the degree of OTM compared with the vehicle-treated or control group (P > .05). When BMP-2 was combined with corticotomy on the tension and pressure sides (corticotomy plus BMP-2 group), respectively, nonsignificant OTM rates were observed (P > .05) compared with the controls; however, decreased osteoclast counts, bone resorption, and clinical results were observed in the corticotomy plus BMP-2 group. Conclusions: In contrast to reports published to date, the present preliminary study suggests that there are limits to OTM acceleration by bone formation on the tension side and agrees with the idea that there is a single continuous periodontal compartment in OTM, rather than a pressure side and a tension side.

Pharyngeal Airway Changes Associated With Maxillary Distraction Osteogenesis in Adult Cleft Lip and Palate Patients

2012-02-01

Purpose: To investigate 1) the changes in pharyngeal airway sizes associated with maxillary distraction osteogenesis and 2) the correlations between maxillary skeletal variables and the pharyngeal airway in adult patients with cleft lip and palate. Patients and Methods: The study was carried out in 14 adult subjects with cleft lip and palate. Predistraction records were taken at a mean age of 22.7 ± 4.6 years. All patients had placement of a rigid external distraction device (RED I; KLS Martin, Tuttlingen, Germany) after Le Fort I osteotomy. Lateral cephalograms were assessed before surgery and at short-term follow-up (8.0 ± 6.4 months). The cephalometric skeletal and pharyngeal airway variables were statistically evaluated by use of the Wilcoxon signed-rank test. Spearman ρ correlation was performed to check the correlations between maxillary skeletal and pharyngeal variables. Results: The maxillary movement was 8.7 mm (P < .01). The maxillary depth angle (+7.9°) and effective maxillary length (9.4 mm) increased significantly (P < .01) after distraction, whereas the palatal plane angle remained unchanged. Anterior nasal spine (8.2 mm) and Posterior nasal spine (6.9 mm) moved anteriorly. The overjet increased (9.5 mm) significantly (P < .01). Posterior, superoposterior, and middle airway spaces increased significantly, with mean differences of 7.5 mm, 5.1 mm, and 3.3 mm, respectively. The soft palate moved anteriorly, with the greatest movement at its superior point. Significant positive correlations were observed for the posterior and superoposterior airway spaces and maxillary movement. PNS changes showed the highest correlation with posterior airway changes. Conclusions: The significant anterior movement of the maxilla resulted in significant increases in posterior, superoposterior, and middle airway spaces. The posterior airway space showed the highest significant positive correlation with the movement of PNS. The posterior and superoposterior airway spaces also showed significant positive correlations with the maxillary skeletal variables.

Orthognathic Surgery and Partial Glossectomy in a Patient With Merosin-Deficient Congenital Muscular Dystrophy

Lewis C. Jones, Peter D. Waite — 2012-02-01

Muscular dystrophy (MD) describes a group of hereditary muscular diseases. The molecular mechanisms that cause the different forms of MD vary, as do the incidence and impact on a patient's quality of life. The most common form, Duchenne MD, follows an X-linked inheritance pattern and occurs with an incidence of approximately 1 in 3,500 live-born male infants. However, rarer forms such as congenital MD (CMD) also exist. CMD has an autosomal recessive inheritance pattern that, according to 1 Italian sample, has an incidence of only 0.7 per 100,000 live births. CMD is characterized by severe muscle hypotonia (first noticeable at birth or within the first months of life), generalized muscle weakness, and muscle contractures of varying severity that result in delayed or missed developmental motor milestones. Each type of CMD is subclassified based on the specific molecular defect or deficiency.

Survey of Residents Who Have Participated in Humanitarian Medical Missions

Shahid R. Aziz, Vincent B. Ziccardi, Sung-Kiang Chuang — 2012-02-01

Purpose: To survey physicians who participated in humanitarian missions as residents to assess the value of this experience on residency training and future career choices. Materials and Methods: An anonymous 26-question survey was electronically mailed to 45 individuals identified as having participated in a cleft lip/palate mission during residency. The survey was created and distributed, and the data were collected using the online survey engine Survey Monkey. Results: Thirty-nine individuals (86.7%) completed the survey. Of these, 27 were men (69.2%) and 12 were women (30.8%). Thirty-two (82.1%) were oral and maxillofacial surgeons, 4 (10.3) were plastic and reconstructive surgeons, 1 (2.6%) was an otolaryngologist, and 2 (5.1%) were pediatric dentists. Twenty-five respondents (64.1%) stated that, before their first mission, they had not operated on a primary cleft lip; 21 (53.8%) noted that they had not operated on a primary cleft palate before their first mission. Thirty-six (92.3%) noted that their mission experience improved their ability to repair facial clefts. Thirty-seven (94.9%) believed their mission experience improved their overall surgical skill. All respondents (n = 39, 100%) believed their mission experience improved their overall ability to evaluate patients with cleft. Thirty-six (92.3%) believed their experience in humanitarian missions made them more culturally sensitive/competent health care providers. Thirty-eight respondents (97.4%) believed these missions made them more socially aware of the differences in access/availability of health care globally. Thirty-eight (97.4%) believed that participation in a humanitarian mission was a high point of their residency. Thirty-seven (94.9%) planned to participate in humanitarian medical missions during their career after residency. Conclusion: All respondents believed that participation in a humanitarian mission during residency was a positive part of their training. In addition, these missions allowed the residents to develop as surgeons and improve their awareness of global health care and cultural competence. Given these important educational aspects, participation in a humanitarian mission should be considered a required part of residency training.

Longitudinal Observation of Mandibular Motion Pattern in Patients With Skeletal Class III Malocclusion Subsequent to Orthognathic Surgery

Ellen Wen-Ching Ko, Chiung Shing Huang, Lun-Jou Lo, Yu-Ray Chen — 2012-02-01

Purpose: The aims of the present study were to delineate the characteristic patterns of 3-dimensional (3D) mandibular movement in patients with skeletal Class III malocclusion compared with normal individuals and to investigate the longitudinal changes in mandible and condylar motion after orthognathic surgery (OGS). Patients and Methods: The subjects in the present prospective study consisted of 2 groups. The OGS group included 24 patients with skeletal Class III who underwent OGS. The control group consisted of 25 patients who underwent orthodontic treatment only. The patient records included demographic data, lateral and posteroanterior cephalometric radiographs before treatment, and serial mandibular motion data. In the OGS group, the mandibular motion data were obtained before OGS (T1), 1 month after OGS (T2), and at least 6 months after OGS (T3). The differences in cephalometric measurements and mandibular movements between the 2 groups were compared. The Pearson correlation test was performed to assess the relationship between the cephalometric measurements and the mandibular movements. Serial changes in mandibular movement in the OGS group were also compared. Results: The skeletal pattern in the OGS group demonstrated retrusive maxilla and a protrusive mandible, with a larger mandibular plane angle. For the incisal range of motion, the OGS group's maximal mouth opening was larger than the control group's by 6.9 mm. In the OGS group, the condylar range of motion in retrusion and the Bennett angle were asymmetric. Skeletal Class III patients tended to have a smaller range of condylar retrusion. At 1 month after OGS, the maximal incisal range of motion decreased from 57.23 to 25.61 mm. Other variables, including laterotrusion, movement velocity, and angle and distance of condylar movement in protrusion, reduced significantly. The Bennett angle demonstrated increased symmetry on both sides. Six months after OGS, the condylar motion in opening demonstrated improvements, but to a lesser extent than at T1. The condylar motion in retrusion recovered totally. The maximum incisal range of motion reduced slightly, but remained similar in value to that of the control group. The variables, including laterotrusion, movement velocity, and angle and distance of condylar movement in protrusion, demonstrated total recovery. The mandibular movement variables at T3 were not significantly different from those of the control group. Conclusions: Skeletal Class III patients demonstrated a larger maximal mouth opening than did the controls, along with similar laterotrusion, but with a smaller retrusive condylar range of movement. The range of incisor motion and condylar movement did not correlate. The deterioration in mandibular motion after OGS can recover totally within 6 months. At T3, the mandibular movement remained consistent with the amount in normal subjects.

Cranioplasty With Custom-Made Implants: Analyzing the Cases of 10 Patients

2012-02-01

Purpose: The aim of this study was to assess quantitatively whether a symmetric reconstruction of the calvaria could be achieved using 3-dimensional (3D) custom-made implants and to examine any complications caused by the cranioplasty. Patients and Methods: Custom-made cranial implants were produced using data obtained from computed tomographic scanning of the defect using computer-aided design and rapid prototyping techniques. Polymethylmethacrylate was used as the reconstruction material and the implant was cast from a silicone rubber mold. These implants were used in 10 patients (9 men and 1 woman) who previously received a craniectomy. The symmetry gained after cranioplasty was quantified by volumetric analysis using 3D reconstructed postoperative computed tomographic imaging. Any complications after cranioplasty also were recorded. Results: The average follow-up was 42.5 months (range, 7 to 85 mo). The esthetic appearance of all patients was much improved. When the volume of the reconstructed right calvaria was compared with the left calvaria, the difference was not statistically significant (P > .05). There were 2 cases of complications. One exhibited a transient seroma collection. Another had a wrinkle formation in the forehead. No infectious episodes or signs of plate rejection were encountered. Conclusions: The custom-made implants for cranioplasty showed a significant improvement in morphology. The implants may be very useful for repairing large and complex-shaped cranial defects. The technique may be useful for the bone reconstruction of other sites.

Survival After Free Flap Reconstruction in Patients With Advanced Oral Squamous Cell Carcinoma

2011-06-20

Purpose: The purpose of the present study was to assess the effect of free-flap reconstruction on the survival of patients treated for oral squamous cell carcinoma. Patients and Methods: The present study was based on a retrospective cohort of 98 patients. Of the 98 patients, 49 underwent surgical reconstruction with microvascular tissue transfer (test group) and in 49 (control group), only local or regional flaps were used. Results: For the free-flap group, the average follow-up period was 34.6 months. For the control group, the average follow-up was 39.8 months. At the end of the follow-up period, 23 (47%) and 33 (67.3%) patients had died of oral squamous cell carcinoma in the microvascular reconstructive and control group, respectively. The difference in the final status between the 2 groups was statistically significant (P = .03). In the free-flap group, the mean and median survival time was 65 and 60 months. In the locoregional flap group, the mean and median survival time was 54 and 24 months, respectively. No difference was seen in the survival time between the free-flap and local flap groups (P = .2). Univariate Kaplan-Meier analysis revealed that positive surgical margins were significantly associated with shortened survival in the free-flap group and that recurrence was significant in both reconstructive groups. On multivariate Cox regression analysis, the status of the resection margin (P = .07) and tumor recurrence (P < .0005) showed a significant relationship with survival. Conclusion: Patients with free-flap reconstruction of surgically created defects after oral cancer resection showed a trend toward better 5-year survival.

Survival After Free Flap Reconstruction in Patients With Advanced Oral Squamous Cell Carcinoma

Remy H. Blanchaert — 2012-02-01

I read with great interest the article by deVincente et al. As a clinician active in the management of patients with malignant tumors of the oral cavity, I was hoping for an increased support of the costly and time-consuming interventions undertaken on behalf of patients with oral cancer. Despite its title, however, the article did not identify a survival advantage to treatment by a microvascular free tissue transfer or a locoregional flap. In fact, the article identified rates of recurrence of nearly 50% for either study group. What this indicates to me is that the biologic behavior of the tumor is the determining factor in survival.

Stereotactic Radiosurgery in Combination With Chemotherapy as Primary Treatment for Head and Neck Cancer

2011-07-18

Purpose: The purpose of this study was to investigate the effect of stereotactic radiosurgery on local control and organ preservation in cases of primary head and neck cancer. Patients and Methods: In this retrospective study, 14 patients with a mean age of 73 years were treated between March 2006 and September 2007 with stereotactic radiosurgery for the management of primary head and neck cancer. The patients had biopsy confirmation of disease before treatment and all patients were confirmed with squamous cell carcinoma. The staging consisted of T2 (5 cases), T3 (3 cases), T4 (6 cases), N0 (13 cases), and N1 (1 case). Marginal doses were 3,500 to 4,200 cGy in 3 or 5 fractions. The outcome was assessed according to Response Evaluation Criteria in Solid Tumors criteria based on magnetic resonance imaging and positron emission tomography/computed tomography. Results: Significant tumor reduction was noted at the third month of follow-up with 5 complete responses and 9 partial responses. At a mean follow-up of 36 months (range, 14-40 mo) the local control and overall survival rates were 71.4% (10/14) and 78.6% (11/14), respectively. Conclusions: These results show the feasibility of using stereotactic radiosurgery for primary head and neck cancer and its potential benefit in local control and organ preservation.

PET-MRI Fusion in Head-and-Neck Oncology: Current Status and Implications for Hybrid PET/MRI

2011-05-23

Purpose: To review the current status and clinical effect of PET-MRI image fusion in the staging of head-and-neck cancer and to show its implications for imaging with future hybrid PET/MRI scanners. Materials and Methods: We reviewed the current literature in order to provide an overview of the potential of the combination of the anatomic and functional imaging capabilities of magnetic resonance imaging (MRI) and of the potential for molecular and metabolic imaging with Positron emission tomography (PET). The research question was whether these image devices might be of synergistic value. Results: PET with [18F]-fluorodeoxyglucose has shown promising results for the assessment of lymph node involvement in cancer, the identification of distant metastasis and synchronous and metachronous tumors, and the evaluation of tumor recurrence or carcinoma of an unknown primary. For morphologic imaging, MRI has several advantages compared with computed tomography in the head-and-neck area. This is mainly because of the superior soft tissue contrast and fewer artifacts from dental implants. Moreover, MRI allows functional imaging, such as the assessment of perfusion with dynamic contrast-enhanced MRI. The published data indicate that image fusion should be beneficial in the case of the recurrence of oromaxillofacial cancer and in the evaluation of potential metastatic lymph nodes. However, retrospective image fusion is technically demanding in the head-and-neck area, mainly because of the varied patient positions used for the various scanners and the anatomic complexity of this region. Conclusions: Combined PET/MRI scanners might overcome the above-named problems. Both sequential and fully integrated PET/MRI scanners are now available in selected departments, and future studies will show whether hybrid PET/MRI is of greater clinical value than PET/CT and retrospective image fusion techniques.

Long-Term Results From Soft and Hard Tissue Augmentation by a Modified Vascularized Interpositional Periosteal-Connective Tissue Technique in the Maxillary Anterior Region

Chang-Sung Kim, Yong-Ju Jang, Seong-Ho Choi, Kyoo-Sung Cho — 2011-07-11

The predictability of implant procedures and long-term stability are directly related to the osseous tissue available for implant placement. Alveolar bone resorption after teeth extraction occurs 3 dimensionally and is sometimes associated with different anatomic or pathologic conditions. Most bone resorption occurs within the initial 3 months after tooth extraction. In the anterior area, volumetric alterations of the alveolar ridge and associated soft tissue defects can be unfavorable for endosseous implant placement and implant esthetics; therefore, soft and hard tissue augmentations are necessary for long-term survival and esthetic results. Immediate placement of the implant after tooth extraction has been suggested to prevent alveolar bone resorption. However, even after placement of an implant into a fresh extraction socket, alveolar bone resorption could not be prevented and the extraction socket was remodeled in a healing pattern different from the natural tooth site. It has been reported that thicker bone is needed to guarantee sufficient bone height around the implant. Because alveolar bone resorption and soft tissue deformation are expected after tooth extraction, a specific type of ridge augmentation or preservation technique should be considered to achieve esthetic and functional results. Such techniques mainly include bone graft and guided bone regeneration. Currently, guided bone regeneration using a barrier membrane is considered the standard of care to increase the width and height of the alveolar ridge.

Desired Characteristics of a Potential Oral and Maxillofacial Surgery Practice Associate: A Connecticut Survey Response

Petar Hinic, Michael P. Johnson, John P.W. Kelly — 2011-05-09

Purpose: The goal of the survey was to identify the desired characteristics of recently graduated oral surgeons entering private practice in Connecticut and compare these results to a similar study conducted earlier in New Jersey. Materials and Methods: An anonymous survey was mailed to all active members of the Connecticut Society of Oral and Maxillofacial Surgeons in February 2010. The response rate for the survey was 63%, with 69 of 110 surveys returned. Conclusions: The most valued characteristics of a new associate included board certification; clinical competence in dentoalveolar surgery, anesthesia, and implant surgery; and personal character. These results paralleled the results of the New Jersey survey.

News and Announcements

2012-02-01

All abstract and poster applications for the upcoming AAOMS 94th Annual Meeting, Scientific Sessions and Exhibition and the Maxillofacial Oncology and Reconstructive Surgery (MORS) preconference program must be submitted by Thursday, March 15, 2012 via the online submission process.

Reader's Circle Continuing Education Program

2012-02-01

Readers now have the opportunity to participate in the Reader's Circle Program via the JOMS Web site. By using the electronic system, readers will be able to immediately access the answers and receive CE credit. We will continue to offer the print version of Reader's Circle, but highly encourage all readers to use the online version.

Masthead

2012-02-01

(ISSN 0278-2391) is published monthly by Elsevier Inc, for the American Association of Oral and Maxillofacial Surgeons, 360 Park Avenue South, New York, NY 10010-1710. Business Office: 1600 John F. Kennedy Blvd, Ste 1800, Philadelphia, PA 19103-2899. Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2012-02-01

AAOMS Author Disclosure forms

2012-02-01

Journal of Oral and Maxillofacial Surgery

Let's Not Skew Ourselves

Is Clonidine an Adequate Alternative to Epinephrine as a Vasoconstrictor in Patients With Hypertension?

Verification of Nerve Integrity After Surgical Intervention Using Quantitative Sensory Testing

Prevalence and Management of Fourth Molars: A Retrospective Study and Literature Review

Iatrogenic Displacement of Lower Third Molar Roots Into the Sublingual Space: Report of 6 Cases

Temporomandibular Custom Hemijoint Replacement Prosthesis: Prospective Clinical and Kinematic Study

Comparison of Current Perception Threshold Electrical Testing to Clinical Sensory Testing for Lingual Nerve Injuries

Telemedicine as an Effective Tool for the Management of Temporomandibular Joint Disorders

Bilateral Temporomandibular Joint Dislocation With Locked Mandibular Impaction

Assessing Validity of Actual Tooth Height and Width From Cone Beam Images of Cadavers With Subsequent Dissection to Aid Oral Surgery

Does Implant Staging Choice Affect Crestal Bone Loss?

Evaluation of Satisfaction of Patients Rehabilitated With Zygomatic Fixtures

Multilocularity as a Radiographic Marker of the Keratocystic Odontogenic Tumor

Bisphosphonate-Related Osteonecrosis of Jaws in 3 Osteoporotic Patients With History of Oral Bisphosphonate Use Treated With Single Yearly Zoledronic Acid Infusion

Intraosseous Venous Malformation of the Mandible: A Review on Interdisciplinary Differences in Diagnostic Nomenclature for Vascular Anomalies in Bone and Report of a Case

Cervicofacial Necrotizing Fasciitis and Steroids: Case Report and Literature Review

Surgical Treatment for Nontuberculous Mycobacterial (NTM) Cervicofacial Lymphadenitis in Children

Traumatic Ulcerative Granuloma With Stromal Eosinophilia: Report of a Case and Literature Review

Role of Early Diagnosis and Multimodal Treatment in Rhinocerebral Mucormycosis: Experience of 4 Cases

Ectopic Thyroid Gland in the Mandible: A Case Report and Review

Pigmented Villonodular Synovitis of the Temporomandibular Joint Presenting as a Middle Cranial Fossa Tumor

Homo Neanderthalensis; First Documented Benign Intraosseous Tumor in Maxillofacial Skeleton

Giant Rhinophyma of the Nose

Preoperative Evaluation of Spatial Relationship Between Inferior Alveolar Nerve and Fibro-osseous Lesion by High Resolution Magnetic Resonance Neurography on 3.0-T System: A Case Report

Can an Arch Bar Replace a Second Lag Screw in Management of Anterior Mandibular Fractures?

Endoscope-Assisted Transoral Reduction and Internal Fixation Versus Closed Treatment of Mandibular Condylar Process Fractures—A Prospective Double-Center Study

Dental Injuries in Pediatric Patients With Facial Fractures Are Frequent and Severe

Risk Factors for Neurosensory Disturbance After Bilateral Sagittal Split Osteotomy Based on Position of Mandibular Canal and Morphology of Mandibular Angle

Automated Continuous Mandibular Distraction Osteogenesis: Review of the Literature

Subjective Outcomes of Maxillomandibular Advancement Surgery for Treatment of Obstructive Sleep Apnea Syndrome

Revisiting the Supraforaminal Horizontal Oblique Osteotomy of the Mandible

Bone Regeneration and Docking Site Healing After Bone Transport Distraction Osteogenesis in the Canine Mandible

Human Masseter Muscle Fiber Type Properties, Skeletal Malocclusions, and Muscle Growth Factor Expression

Bilateral Parotid Duct Obstruction After Rhytidectomies: Case Report

Corticotomy-Assisted Orthodontic Enhancement by Bone Morphogenetic Protein-2 Administration

Pharyngeal Airway Changes Associated With Maxillary Distraction Osteogenesis in Adult Cleft Lip and Palate Patients

Orthognathic Surgery and Partial Glossectomy in a Patient With Merosin-Deficient Congenital Muscular Dystrophy

Survey of Residents Who Have Participated in Humanitarian Medical Missions

Longitudinal Observation of Mandibular Motion Pattern in Patients With Skeletal Class III Malocclusion Subsequent to Orthognathic Surgery

Cranioplasty With Custom-Made Implants: Analyzing the Cases of 10 Patients

Survival After Free Flap Reconstruction in Patients With Advanced Oral Squamous Cell Carcinoma

Survival After Free Flap Reconstruction in Patients With Advanced Oral Squamous Cell Carcinoma

Stereotactic Radiosurgery in Combination With Chemotherapy as Primary Treatment for Head and Neck Cancer

PET-MRI Fusion in Head-and-Neck Oncology: Current Status and Implications for Hybrid PET/MRI

Long-Term Results From Soft and Hard Tissue Augmentation by a Modified Vascularized Interpositional Periosteal-Connective Tissue Technique in the Maxillary Anterior Region

Desired Characteristics of a Potential Oral and Maxillofacial Surgery Practice Associate: A Connecticut Survey Response

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