Journal of Oral and Maxillofacial Surgery - Articles in Press

Bisphosphonate-Related Osteonecrosis of the Jaw: Is pH the Missing Part in the Pathogenesis Puzzle? - Corrected Proof

2010-02-08

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) is a side effect of bisphosphonate therapy, primarily diagnosed in patients with cancer and metastatic bone disease and receiving intravenous administrations of nitrogen-containing bisphosphonates. If diagnosis or treatment is delayed, BRONJ can develop to a severe and devastating disease. Numerous studies have focused on BRONJ, with possible pathomechanisms identified to be oversuppression of bone turnover, ischemia due to antiangiogenetic effects, local infections, or soft tissue toxicity. However, the precise pathogenesis largely remains elusive and questions of paramount importance await to be answered, namely 1) Why is only the jaw bone affected? 2) Why and how do the derivatives differ in their potency to induce a BRONJ? and 3) Why and when is BRONJ manifested? The present perspective reflects on existing theories and introduces the hypothesis that local tissue acidosis in the jaw bone offers a conclusive pathogenesis model and may prove to be the missing link in BRONJ.

Use of Panoramic X-Ray to Determine Position of Impacted Maxillary Canines - Corrected Proof

2010-02-08

Purpose: To evaluate the position of impacted maxillary canines in the alveolus using panoramic radiographs.Materials and Methods: The present study was a retrospective chart review of 102 patients with 130 impacted maxillary canines from the University of Illinois at Chicago College of Dentistry and private practice. Of the 130 impacted maxillary canines, 59 were impacted buccally and 71 were impacted palatally. The inclination of the impacted maxillary canines to a horizontal line from the mesiobuccal cusps of the maxillary molars was measured. We used these measurements to predict the position of the tooth and correlate this prediction with the actual approach used during surgery.Results: The mean angulation of the buccally impacted maxillary canines was 75.1° ± 18.2° (range, 8° to 111°). The mean angulation of the palatally impacted maxillary canines was 51.3° ± 15.3° (range, 12° to 91°). The mean difference between the angulation of the impacted maxillary canines as measured on the panoramic radiographs was statistically significant (P < .001). From a receiver-operator characteristic curve and using a logistic regression model, impactions greater than 65° were 26.6 times more likely to be buccally impacted maxillary canines (P < .001).Conclusions: Panoramic radiographs are useful for predicting the location of impacted maxillary canines and the subsequent surgical approach required for exposure and orthodontic appliance attachment when computed tomography is unavailable or unnecessary otherwise. The use of panoramic radiographs for determing impacted maxillary canine position has a high sensitivity and specificity, with angulations greater than 65° associated with buccal impactions.

Sodium Hyaluronate Improves Outcomes After Arthroscopic Lysis and Lavage in Patients With Wilkes Stage III and IV Disease - Corrected Proof

2010-02-08

Purpose: Among patients with Wilkes stage III and IV disease undergoing arthroscopic lysis and lavage, does the use of an intra-articular injection of sodium hyaluronate (SH), when compared with Ringer lavage, result in better postoperative pain control and temporomandibular joint (TMJ) function?Patients and Methods: We designed and implemented a randomized, double-blind, pilot controlled clinical trial. The study sample was composed of patients with middle Wilkes stage (late stage III and early stage IV) disease. Subjects were randomized to 1 of 2 treatment limbs. The treatment group received Ringer lactate plus an injection of 1 mL of SH after arthroscopy, whereas the control group was given Ringer lactate during arthroscopy. The primary outcome variables were pain and TMJ function measured by use of visual analog scales. Appropriate descriptive and bivariate statistics were computed. A P value less than .05 was considered statistically significant.Results: The study sample was composed of 40 patients with 20 subjects enrolled in both treatment groups. There were no statistically significant differences between the 2 groups in terms of demographics and preoperative variables. Postoperative analgesia was statistically significant in the treatment group with respect to the control group on the visits on days 14 and 84. No statistically significant differences were observed between the 2 groups in the maximum interincisal opening and tolerance.Conclusions: An intra-articular injection of SH after arthroscopic lysis and lavage is effective in reducing pain in patients with TMJ dysfunction, enhancing postsurgical recovery. The analgesic effect of treatment with SH is maintained in the long term.

Osteonecrosis or Metastases of the Jaw or Both? Case Report and Review of the Literature - Corrected Proof

Sven Otto, Kirsten Schuler, Stephan Ihrler, Michael Ehrenfeld, Gerson Mast — 2010-02-08

The first description of bisphosphonate-related osteonecrosis of the jaw (BRONJ) was published by Marx in 2003. BRONJ is currently a well-known and serious side effect of bisphosphonate treatment that is still poorly understood. According to the American Association of Oral and Maxillofacial Surgeons task force on BRONJ, diagnosis is made by the presence of exposed bone in the maxillofacial region over a period of 8 weeks in patients with a history of current or previous treatment with bisphosphonates and no history of radiation therapy to the jaws.

Frequency of Bleeding Following Invasive Dental Procedures in Patients on Low-Molecular-Weight Heparin Therapy - Corrected Proof

2010-02-08

Purpose: The purpose of this study was to determine the frequency of bleeding complications after invasive dental procedures in patients on low-molecular-weight heparin (LMWH) therapy.Materials and Methods: A chart review of patients who underwent invasive dental procedures while on LMWH therapy was conducted. The following information was obtained: demographics, medical history, social history, medications, relevant laboratory values, postoperative bleeding events, and use of local hemostatic agents and blood products.Results: Forty-one patients (21 men) were identified with 42 dental appointments. The mean age was 48 years (range, 16 to 78 years). Thirty-seven patients (90%) were on LMWH therapy for deep venous thrombosis prophylaxis. Thirty-one patients (76%) were on concomitant medications that may potentiate bleeding. Multiple dental extractions (range, 2 to 14 teeth) were performed during 19 dental appointments. Twenty-one appointments were for single-tooth extraction and 2 were for soft tissue biopsies. Three patients (7%) had postextraction bleeding events. All 3 patients were on LMWH (enoxaparin) and warfarin therapy concurrently. One patient had persistent bleeding after extraction of 4 teeth (international normalized ratio, 1.6), which was successfully controlled with topical thrombin, administration of vitamin K and fresh frozen plasma, and discontinuation of enoxaparin and warfarin. Postoperative bleeding in the other 2 patients was managed successfully with local hemostatic measures and home care instructions.Conclusion: Our study suggests that, although postoperative bleeding in patients on LMWH therapy alone is rare to nonexistent, patients on warfarin and LMWH may be at increased risk of bleeding after invasive dental procedures.

Scintigraphic Evaluation of Osteoblastic Activity in Extraction Sockets Treated With Platelet-Rich Fibrin - Corrected Proof

2010-02-08

Purpose: To evaluate the effect of platelet-rich fibrin (PRF) on the early bone healing process with bone scintigraphy based on technetium-99m methylene diphosphonate uptake in third molar extraction sockets.Patients and Methods: Fourteen patients with bilaterally soft tissue impacted third mandibular molars were included in the study. The right and left impacted third molars were surgically extracted in the same session. PRF was randomly administered into one of the extraction sockets, whereas the contralateral sockets were left without treatment. Four weeks after surgery, scintigrams were obtained to evaluate scintigraphic differences between PRF-treated and non–PRF-treated sockets. After completion of the clinical study, PRF samples were evaluated by light and scanning electron microscopy.Results: The average increase in technetium-99m methylene diphosphonate uptake as an indication of enhanced bone healing did not differ significantly between PRF-treated and non–PRF-treated sockets 4 weeks postoperatively (P > .05). Abundant fibrin and inflammatory cells were observed by light microscopic examination of PRF samples. Scanning electron microscopic analysis of PRF revealed the existence of platelet aggregates in a fibrin network and crystalline particles on the outer surface of PRF.Conclusions: PRF might not lead to enhanced bone healing in soft tissue impacted mandibular third molar extraction sockets 4 weeks after surgery. PRF exhibits the potential characteristics of an autologous fibrin matrix. However, whether the presence of crystal-like particles on the outer surface of PRF alters bone healing should be investigated further.

Cryptogenic Stroke and Parotid Tumor Surgery: A Case Report - Corrected Proof

2010-02-01

Parotid tumor surgery has been rarely complicated by cerebral vascular accidents, and the occurrence of a stroke after an operation of the parotid gland for the removal of a tumor seems to be a very unusual complication, having been reported in the literature only once thus far.

Effects of Postoperative Radiotherapy for Temporomandibular Joint Ankylosis After Gap Arthroplasty: An Animal Study Using Sheep - Corrected Proof

2010-02-01

Purpose: The aim of the present study was to examine the effects of postoperative irradiation on reducing heterotopic bone formation after gap arthroplasty release of temporomandibular joint ankylosis.Materials and Methods: Five sheep underwent induction of right temporomandibular joint ankylosis. After 3 months, the ankylosis was released by gap arthroplasty. At 24 hours after the release, they received a single radiation dose of 10 Gy. All sheep were sacrificed at 3 months after gap arthroplasty release. The body weight, jaw opening amount, and radiographs were measured at key intervals, with histologic assessment after death. The findings were compared with those in a control group treated with gap arthroplasty without irradiation.Results: The clinical measurements, radiographs, and histologic findings all revealed less evidence of reankylosis in the irradiated sheep.Conclusion: The results of the present study have shown that a single radiation dose at 24 hours after gap arthroplasty for temporomandibular joint ankylosis inhibits heterotopic ossification.

Aneurysmal Bone Cysts of the Jaws: Analysis of 17 Cases - Corrected Proof

Zhi-Jun Sun, Yi-Fang Zhao, Rui-Li Yang, Roger A. Zwahlen — 2010-01-28

Purpose: Aneurysmal bone cysts (ABCs) are benign osteolytic lesions that occur relatively rarely in the jaws. The aim of the present study was to investigate the clinical and radiographic characteristics, pathologic features, and treatment results of ABCs of the jaws (JABCs).Materials and Methods: A retrospective analysis of a 20-year database, including 17 cases of JABC, was performed.Results: A total of 17 patients, 9 males and 8 females, aged 7 to 47 years (mean 20.4, median 14), were included. Of the 17 lesions, 15 (88.2%) were located in the mandible and 2 (11.8%) in the maxilla. A painless (12 of 17, 70.6%) or painful (3 of 17, 17.6%) swelling was the most common clinical finding. The pathologic analyses revealed that 13 JABCs (76.5%) were secondary in nature, including 11 cases associated with ossifying fibroma. Radiologically, the lesions frequently presented as multilocular (58.8%), well-defined (70.6%) radiolucencies (82.4%). Two lesions (11.8%) recurred.Conclusions: Our results suggest that most JABCs are secondary in nature and frequently associated with ossifying fibroma. The patients with JABCs presented with various clinical and radiographic features and therefore often posed a diagnostic dilemma. Resection is the preferred treatment of JABCs.

Frequency of Agenesis, Impaction, Angulation, and Related Pathologic Changes of Third Molar Teeth in Orthodontic Patients - Corrected Proof

Mevlut Celikoglu, Ozkan Miloglu, Fatih Kazanci — 2010-01-25

Purpose: The objectives of the present study were to investigate the frequency of impaction, agenesis, angular position, and related pathologic changes of third molar teeth in a group of orthodontic patients.Materials and Methods: Our sample included the panoramic radiographs of 351 orthodontic patients aged 20 to 26 years (mean 22.8). The descriptive characteristics of agenesis, impaction, angular position, and pathologic changes of third molars were recorded. The χ2 test was used for analysis.Results: The proportion of third molar agenesis was 17.3% with no statistically significant gender differences (18.4% for women and 15.8% for men). The frequency of impacted third molars (ITMs) was 35.9% (24.2% in men and 45.0% in women; P < .05). The frequency of maxillary ITMs was 43.2% (192 of 444 teeth), and the frequency of mandibular ITMs was 56.8% (252 of 444 teeth). The position observed most often was mesioangular inclination, with a frequency of 50.0%. Only 10.4% of the ITM teeth were affected by any pathologic changes, and most of these changes were associated with the horizontal position.Conclusions: The present results showed that agenesis accounted for 17.3% and impaction for 35.9% of the pathologic features in this group of Turkish orthodontic patients aged 20 to 26 years of age. Mesioangular inclination was seen in 50.0%, and a small proportion (10.4%) had pathologic changes of the ITMs.

Comparison of Titanium and Biodegradable Miniplates for Fixation of Mandibular Fractures - Corrected Proof

2010-01-25

Purpose: The purpose of the present study was to compare the use of biodegradable miniplates and titanium miniplates for the fixation of mandibular fractures.Patients and Methods: BioSorb FX biodegradable plates and screws and titanium miniplates were used in 91 patients (65 males and 26 females; age range 11 to 69 years) for the treatment of mandibular fractures. The clinical and radiographic findings were recorded at 1, 3, 6, and 12 months after surgery.Results: The overall complication rate was 4.41%. In the biodegradable plate group, infection occurred in 2 cases (4.26%) and was resolved by incision and drainage and antibiotics. In the titanium plate group, infection occurred in 1 case and plate fracture in 1 case (4.56%). The fractured plate was removed, and a new titanium miniplate was applied using a trocar. The infection was resolved with antibiotics. No adverse tissue reactions, malocclusions, or malunions occurred during the observation period.Conclusions: Our results have shown that the rate of morbidity is very low with the use of biodegradable plates and titanium plates, suggesting that biodegradable and titanium plates have the potential for successful use in the fixation of mandibular fractures.

Unilateral Parotid Gland Involvement With Synchronous Multiple Basal Cell Adenocarcinomas: Case Report and Review of the Literature - Corrected Proof

Jingzhou Hu, Zhiyuan Zhang, Jiawei Zheng, Weimin Ye, Zhen Tian, Hanguang Zhu — 2010-01-25

Salivary gland tumors account for about 3% of all head and neck neoplasms. Basal cell adenocarcinoma (BCAC) is a rare malignant neoplasm of the salivary glands that most commonly affects the major salivary glands. Since its inclusion in the World Health Organization classification of salivary gland tumors in 1991, the description of the entity is relatively new, with about 100 cases reported.

Equivalence Randomized Controlled Trial of Bioresorbable Versus Titanium Miniplates in Treatment of Mandibular Fracture: A Pilot Study - Corrected Proof

2010-01-25

Purpose: The present study was undertaken to test bioresorbable fixation versus titanium for equivalence in terms of clinical union and complications using the American Association of Oral and Maxillofacial Surgeons parameters of care. The study design was a randomized, controlled, equivalence trial.Materials and Methods: A total of 40 patients were enrolled and allocated to the titanium group and bioresorbable group using a computerized randomization table. All were plated using standard plating principles. In the bioresorbable group, 2 weeks of maxillomandibular fixation was also used. Evaluation of the study endpoint was done at 8 weeks postoperatively. For statistical analysis, the upper limit of the 95% confidence interval was calculated for failure to achieve the primary outcome variable and compared with the maximal clinically acceptable difference between the standard and test modalities in the failure to achieve clinical union (δ). δ was predetermined as 2%. The other complications were tested for significance using Fisher's exact test.Results: Of the 40 patients, 21 were in the titanium group and 19 were in the bioresorbable group, with 20 men and 1 woman in the titanium group and 18 men and 1 woman in the bioresorbable group. The mean age was 28.7 years in the titanium group and 26.6 years in the bioresorbable group. In the titanium group, the complications noted were nonunion in 0%, malocclusion in 7.7%, continued postoperative swelling in 0%, chronic pain in 2%, infection in 5.2%, an inability to chew hard food after 8 weeks in 7.7%, the need for alternative treatment in 0%, and the need for reoperation in 31%. In the bioresorbable group, the complications were nonunion in 4.17%, malocclusion in 11.1%, swelling in 8.3%, chronic pain in 37.5%, infection in 0%, an inability to chew hard food in 11.1%, the need for alternative treatment in 11.1%, and need for reoperation for plate removal in 0%.Conclusions: The small sample size did not allow any meaningful conclusion to be drawn from the present study in terms of the primary question of achieving union. Both groups matched in outcomes when evaluated only on a clinical basis. The avoidance of repeat surgery for plate removal is a definite advantage of using resorbable plates. However, the results are inconclusive in favor of any particular plating system.

Five-Year Follow-Up of Maxillary Distraction Osteogenesis on the Dentofacial Structures of Children With Cleft Lip and Palate - Corrected Proof

Seda Gürsoy, Jyri Hukki, Kirsti Hurmerinta — 2010-01-18

Purpose: To determine the long-term outcomes of maxillary distraction osteogenesis (DO) on skeletal and dental structures of growing children with cleft lip and palate.Patients and Methods: Severe maxillary deficiencies were treated with a rigid external distractor device followed by a consolidation period. Preoperative and postoperative orthodontic treatment lasted a mean of 14 months and 16 months, respectively. The landmarks on standard lateral cephalometric x-rays were digitized and angular and linear measurements were compared by Student's t test to assess the changes before distraction, after distraction, after consolidation, at 1-year follow-up, and at 2-year follow-up. Long-term follow-up (5 years) was interpreted according to mean values because of the small sample size.Results: During DO, the maxilla was horizontally advanced and moved downward as indicated by the significant changes at the SNA and ANB angles (13°) and at maxillary points A, ANS, and PNS. The increase at the divergence between the maxilla and mandible (ANS-PNS/Me-Go) was found to be significant. The mandible (B, Pg, Me) also moved downward (2-4 mm) and backward (Gn) significantly because of mandibular autorotation. The overjet increased (mean increase, 13.7 mm) and the overbite decreased significantly. The advancement of the upper incisors (13.3 mm) and upper molars (12.3 mm) was slightly more than the skeletal points. In a long-term follow-up (5 years), the ANB angle and horizontal overjet continued to decrease but both values remained positive, indicating a Class I relationship.Conclusions: This cephalometric study of young adolescents with cleft lips and palates found great improvement in dentofacial structure after maxillary DO and stability in maxillary skeletal advancement. During a 5-year follow-up, the achieved dentoskeletal treatment outcome was partly diminished. The extreme need for maxillary advancement or facial correction because of psychosocial stress and providing an easier approach for finalizing osteotomy are the major 2 indications for DO treatment.

Occurrence and Types of Associated Injuries in Patients With Fractures of the Facial Bones - Corrected Proof

2010-01-18

Purpose: To identify the occurrence, types, and severity of associated injuries outside the facial region among patients diagnosed with facial fractures, and to analyze whether there are any factors related to associated injuries.Materials and Methods: This was a cross-sectional study of 401 patients diagnosed with facial fractures during the 2-year period from 2003 to 2004.Results: Associated injuries were observed in 101 patients (25.2%). The most common type of injury was a limb injury (13.5%), followed by brain (11.0%), chest (5.5%), spine (2.7%), and abdominal (0.8%) injuries. Multiple associated injuries were observed in 10% and polytrauma in 7.5%. The mortality rate was 0.2%. The occurrence of associated injury correlated significantly with trauma mechanism and fracture type; high-speed accidents and severe facial fractures were significant predictors of associated injury.Conclusions: Associated injuries are frequent among patients who have sustained facial fractures. The results underscore the importance of multiprofessional collaboration in diagnosis and sequencing of treatment, but also the importance of arranging appropriate clinical rotations for maxillofacial residents in training.

Discectomy as the Primary Surgical Option for Internal Derangement of the Temporomandibular Joint - Corrected Proof

Michael Miloro, Brent Henriksen — 2010-01-18

Purpose: The goal of this study was to evaluate outcomes of patients who underwent temporomandibular joint (TMJ) discectomy without replacement as the primary treatment for internal derangement after failure of nonsurgical therapy.Patients and Methods: Thirty consecutive patients with TMJ internal derangement were treated with discectomy from 2001 to 2007. Four patients were lost to follow-up, and 2 were excluded because of prior joint surgery. Using the standardized Helkimo Anamnestic and Clinical Dysfunction Indexes, 24 patients, or 32 joint surgeries, were evaluated postoperatively, with an average follow-up of 30.8 months (range, 2 to 60 months).Results: All 24 patients showed improvement in mandibular mobility and joint function, as well as reduction in TMJ and muscular facial pain, represented by a clinical dysfunction index of DiO, DiI, or DiII. Preoperatively, all patients had an anamnestic index of AiII, which represented moderate to severe pain in the TMJ and masticatory muscles, and/or locking of the joint before surgery. Postsurgically, 20 of the 24 patients scored an index of DiO or DiI, which correlated with a clinically symptom-free state or only a small, minor dysfunction. TMJ pain, muscle pain, and pain with mobility scored the lowest point index, indicating a subjectively successful outcome.Conclusions: Discectomy of the TMJ as a primary surgical option significantly reduces pain and improves function.

Incidental Discovery of Asymptomatic Radiolucent Lesion of the Posterior Mandible - Corrected Proof

2010-01-14

A 20-year-old patient was referred to the outpatient clinic of the dental service at Diyarbakır Military Hospital (Diyarbakır, Turkey) in February 2006. He was referred to us by his dentist for the evaluation of a mandibular lytic lesion seen on panoramic radiographs. It was well-defined and unilocular ().

Osteonecrosis of the Jawbones in 2 Osteoporosis Patients Treated With Nitrogen-Containing Bisphosphonates: Osteonecrosis Reduction Replacing NBP With Non-NBP (Etidronate) and Rationale - Corrected Proof

2010-01-07

Among the bisphosphonates (BPs), the nitrogen-containing BPs (NBPs), such as zoledronate, risedronate, and alendronate, have antibone-resorptive effects (ABREs) that are much more powerful than those of the non-NBPs, such as etidronate and clodronate (). In the past few years, 1,000 or so cases of osteonecrosis of the jaw (ONJ) have been suspected to be associated with the administration of NBPs. However, the mechanism underlying the osteonecrosis remains unclear, and no effective therapeutic methods have been developed. Because NBPs accumulate in the hydroxyapatite within bone, our concern has been that more cases will develop if NBPs continue to be used as they are now. The situation has been made more complex by 1) NBP-associated ONJ developing even after a pause in NBP treatment, and 2) that ONJ sometimes appears long after discontinuation of NBP therapy, in some cases as long as 12 months after. However, few ONJ cases have been reported in patients treated with non-NBPs, such as etidronate and clodronate. We have previously reported that, in mice, etidronate (a non-NBP), when intraperitoneally co-administered with alendronate (an NBP), competes against the NBP for binding to bone hydroxyapatite and that etidronate can reduce the inflammatory effect of alendronate. These findings led us to expect that etidronate might eliminate an NBP that had already accumulated within bone and might therefore be useful as a substitution drug in NBP-treated patients at risk of ONJ. In the present study, we report the effectiveness of such etidronate-replacement therapy in 2 NBP-treated patients with ONJ and/or osteomyelitis and discuss the rationale for this therapeutic strategy.

Nonunion of Mandibular Midline Osteotomy After Tumor Surgery and Radiation Repaired by Endosseous Implants - Corrected Proof

Daniel Taub, Ramzey Tursun, Lionel Gold, Basem T. Jamal — 2009-12-31

Nonunion of the mandible after microvascular flap reconstruction of defects resulting from tumor surgery is a known but rare complication, occurring in 5% of cases. When nonunion results with the use of microvascular flaps, rigid internal fixation, and radiotherapy, other options to treat the nonunion carry a greater risk of osteomyelitis, osteoradionecrosis, and/or persistent nonunion. Although endosseous implants have been reported to cause mandibular fracture in some cases, our case proposes and supports the use of implants for immobilization and/or prevention of nonunion of the mandible in patients who have a high probability of this complication developing, thereby avoiding plating across the nonunion site with the risk of plate exposure and osteoradionecrosis. This technique permitted a good quality of life in our patient during the healing period. He was able to masticate and phonate properly when compared with other treatment options that would have required external and/or intermaxillary fixation devices.

Position of Mandibular Canal and Ramus Morphology Before and After Sagittal Split Ramus Osteotomy - Corrected Proof

2009-12-31

Purpose: The purpose of this study was to evaluate changes in the mandibular canal and ramus morphology before and after a sagittal split ramus osteotomy.Patients and Methods: The subjects were 30 patients (60 sides) with mandibular prognathism who had undergone bilateral sagittal split ramus osteotomy setback surgery. The mandibular canal position and ramus morphology were measured at the 3 horizontal planes under the mandibular foramen level (level A), 1 cm lower than level A (level B), and 2 cm lower than level A (level C) preoperatively and 1 year postoperatively by computed tomography.Results: Postoperative ramus width, lateral distance, lateral marrow distance, and canal length were significantly larger than the preoperative values at the foramen, 1 cm lower, and 2 cm lower. The mandibular canal completely contacted the lateral cortex without lateral bone marrow in 6 sides (10%) in levels A and B and 4 sides (6.7%) in level C preoperatively and 6 sides (10%) in level C postoperatively.Conclusion: This study suggested that postoperative mandibular canal position was located more posteriorly and the postoperative lateral bone marrow became thicker compared with the preoperative state.

New Arthroscopic Disc Repositioning and Suturing Technique for Treating Internal Derangement of the Temporomandibular Joint: Part II—Magnetic Resonance Imaging Evaluation - Corrected Proof

2009-12-31

Purpose: To evaluate the efficiency of an arthroscopic suturing technique for stabilizing anteriorly displaced discs in patients with internal derangement of the temporomandibular joint (TMJ) by magnetic resonance (MR) imaging.Patients and Methods: Six hundred thirty-nine patients (764 joints) diagnosed as having stages II to V of internal derangement were treated with arthroscopic disc repositioning and suturing from August 2004 to March 2007. Consecutive MR images were used to evaluate internal derangement before and approximately 1 to 7 days after the operation for all 639 patients. The disc position of the TMJ was judged according to the success criteria, which included 3 different sagittal planes (lateral, central, and medial). Operative efficiency in those patients, whose discs of the TMJ were affirmed to be in a normal position in all 3 planes, was evaluated to be excellent. Those patients whose discs were in a normal position in 2 planes were evaluated to be good. The others were evaluated to be poor. Cases evaluated as excellent and good were considered success cases (if the disc is displaced only in 1 or 2 planes before operation, the efficiency of the operation would be evaluated as a success only if the whole disc was in normal position).Results: Postoperative consecutive MR images for all 764 joints confirmed that 95.42% (729/764) of the joints were excellent, 3.14% (24/764) were good, and only 1.44% (11/764) were poor. Repeated arthroscopic surgery or open surgery was carried out for the joints that were evaluated as poor.Conclusion: This study indicates that the TMJ arthroscopic suturing technique is effective in repositioning the TMJ disc as confirmed by an MR imaging examination, but long-term follow-up is necessary.

Secondary Surgery for Cicatricial Complications of Facial Injury - Corrected Proof

Irene Tower, Leslie-Ann Lasko, Sandeep Kathju — 2009-12-31

Purpose: To investigate the nature of surgical revision procedures necessitated by cicatricial complications of facial injury.Patients and Methods: All patients who had facial trauma in a period of ∼5 years managed by a single surgeon were reviewed. Of these, 36 were found to have undergone secondary revision procedures arising specifically from scar-related complications.Results: The average age of patients undergoing revision surgery was 34 years; 27 of the 36 patients (75%) were men, and 9 of the 36 (25%) required multiple revision surgical visits. The most common cause of injury was motor vehicle collision; the interval between the initial trauma and the first revision surgery was most commonly 6 to 12 months. Scar-related complications were categorized on the face by anatomic subsite; they occurred most frequently on the forehead/cheeks/chin area, with the eyes/periorbital area the second most frequent location. One hundred twelve discrete surgical procedures (as per current procedural terminology) were performed on these 36 patients to address the cicatricial sequelae of their initial injuries.Conclusions: Facial trauma can frequently entail secondary morbidity in the form of facial scar deposition, which itself can necessitate surgical repair. This represents a substantial but as yet underappreciated health care burden attendant to maxillofacial injury.

Management Protocol for Anaphylaxis - Corrected Proof

Rohit Sharma, Ramen Sinha, P.S. Menon, Deepika Sirohi — 2009-12-28

There is no universal agreement on the definition of anaphylaxis or the criteria for establishing its diagnosis, although it has been known to the field of emergency medicine for more than 100 years. Two meetings were convened by the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network in April 2004 and July 2005. Representatives from 16 different organizations and government bodies, including representatives from developed nations, continue working toward a universally accepted definition, criteria for diagnosis, and management of anaphylaxis. This article presents the latest concepts on anaphylaxis in the literature including the research needs in this area.

Straightforward Management of a Large Pediatric Scalp Degloving Injury in a Combat Zone - Corrected Proof

Thomas F. Kelly, Shane B. Banks, Lee A. Miller — 2009-12-28

Scalp degloving injuries in children can be difficult to manage owing to the disproportionate size of the calvarium. When this type of injury occurs in an environment in which emergency medical care and parental resources are limited, novel methods of treatment require consideration. In the present case, bony fenestrations, negative pressure wound therapy, silver-impregnated dressings, and a split-thickness skin graft were used to completely close a complex severe wound of the soft tissues of the cranium.

Reproducibility of 3 Different Tracing Methods Based on Cone Beam Computed Tomography in Determining the Anatomical Position of the Mandibular Canal - Corrected Proof

2009-12-28

Purpose: To investigate the reproducibility of 3 different tracing methods to determine a reliable method to define the proper anatomical position of the mandibular canal based on cone beam computed tomography (CBCT) data.Materials and Methods: Five dentate and 5 edentate patients were selected at random from the CBCT database. Two independent observers traced both the left and the right mandibular canal using 3-dimensional image-based planning software (Procera System NobelGuide; Nobel Biocare, Göteborg, Sweden). All mandibular canals were traced using 3 different methods. Method I was based on coronal views, also known as cross-sections. Panorama-like reconstructions were the starting point for method II. The third method combined methods I and II.Results: With respect to interobserver reliability, no significant difference (P = .34) for the various methods was observed. The reproducibility was better in edentate than in dentate jaws (P = .0015). The difference between 2 tracings was the lowest for the combined method: within a range of 1.3 mm in 95% of the course of the canal. The most obvious deviations were mainly seen in the anterior part of the canal.Conclusions: The best reproducible method for mandibular canal tracing is the combined method III. Between observers, still a mean 95th percentile deviation threshold of 1.3 mm (SD 0.384) is noted, indicating that a safety zone of 1.7 mm should be respected. When planning surgery on CBCT-based data, surgeons should be aware of the obvious deviations located in the region of the anterior loop of the canal.

Retrospective Review of Microsurgical Repair of 222 Lingual Nerve Injuries - Corrected Proof

2009-12-28

Purpose: Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN.Materials and Methods: A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved “useful sensory recovery” or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes.Results: A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from “useful sensory function” to a “complete return of sensation”) was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to “useful sensory function”), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001).Conclusions: Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.

Surgical Approach to Impacted Mandibular Third Molars—Operative Classification - Corrected Proof

Imad Abu-El Naaj, Refael Braun, Yoav Leiser, Micha Peled — 2009-12-23

Purpose: The aim of the present study is to suggest a convenient way to classify the position of the impacted third mandibular molar relative to the mandibular canal and to suggest indications for the use of each surgical approach for mandibular third molar extraction.Materials and Methods: The presented new typing system, Third Molar Classification (TMC), is a simple and easy-to-apply method for the surgical management of mandibular third molars and can be extended for any ectopic or impacted mandibular tooth. There are 3 major types of third molar positions. The second type is subdivided further into 2 subtypes. In the present study, 9 patients with high-risk mandibular third molars were treated according to the present classification and are presented and discussed. Patients typed as TMC IIb were treated with a sagittal split osteotomy approach and patients typed as TMC III were treated with an extraoral approach.Results: The operative classification was successfully implemented in very rare cases of deeply impacted mandibular third molars. In 3 of 9 cases (33%) minor complications included some degree of hypoesthesia using the extraoral approach; these complications resolved spontaneously without the need for any intervention.Conclusions: The present study describes the use of a new surgical classification system for treatment planning in all types of mandibular third molar extractions. We believe that the present classification could help the oral and maxillofacial surgeon in decision-making and limit the possible risks that are present when attempting to extract impacted mandibular third molars.

Felypressin, but Not Epinephrine, Reduces Myocardial Oxygen Tension After an Injection of Dental Local Anesthetic Solution at Routine Doses - Corrected Proof

Motoaki Inagawa, Tatsuya Ichinohe, Yuzuru Kaneko — 2009-12-23

Purpose: The aim of this study was to evaluate the effect of epinephrine (Epi) or felypressin (Fely) contained in dental local anesthetics on myocardial oxygen balance.Materials and Methods: Male Japanese White tracheotomized rabbits were anesthetized with isoflurane. Three doses of 0.18, 0.36, and 0.72 mL of 2% lidocaine hydrochloride containing 1:80,000 Epi or 3% prilocaine hydrochloride containing Fely 0.03 IU/mL were injected into the rabbit tongue muscle. These doses were equivalent to 2, 4, and 8 of dental local anesthetic cartridges in humans weighing 50 kg by body weight correction, respectively. Heart rate, blood pressure, aortic blood flow, myocardial tissue blood flow, and myocardial tissue oxygen tension were continuously monitored. Data were recorded immediately before and 10, 20, 30, and 60 minutes after the injection.Results: Heart rate decreased in the Fely group. Systolic blood pressure increased in the Epi group, and diastolic blood pressure increased in both groups. Aortic blood flow and myocardial tissue blood flow increased, whereas myocardial tissue oxygen tension did not change in the Epi group. In contrast, aortic blood flow, myocardial tissue blood flow, and myocardial tissue oxygen tension decreased in the Fely group.Conclusion: It is suggested that Fely, but not Epi, decreases myocardial oxygen tension and aggravates myocardial oxygen demand/supply balance even after an injection of dental local anesthetic solution at routine doses.

Ultrasonography for Intraoperative Determination of Tumor Thickness and Resection Margin in Tongue Carcinomas - Corrected Proof

2009-12-23

Purpose: Exact estimation of tumor thickness and the status of the resection margin in tongue carcinoma are important prognostic factors for local recurrence, subclinical nodal metastasis, and survival. This study aims to evaluate the accuracy of intraoral ultrasonography-guided measurement of tumor thickness and define an adequate intraoperative resection margin in squamous cell carcinomas of the tongue.Materials and Methods: In this prospective study, 13 patients with presurgical, biopsy-proven, clinical T1N0 or T2N0 tongue squamous cell carcinomas who underwent a partial glossectomy were examined preoperatively with ultrasonography to assess tumor thickness under general anesthesia. Nine cases underwent resection by a conventional method, whereas we introduced elastic needles with a metal core to mark a deep surgical margin of 10 mm from the deepest tumor invasion front under ultrasonographic monitoring as a new technique in the remaining 4 cases. Each resected specimen was immediately immersed in gelatin solution while maintaining its original shape and orientation and was placed under refrigeration to solidify. Ultrasonographic observations of the gelatin-embedded specimens were performed from the superior surface of the gelatin block.Results: Very fine ultrasonographic images of the resected specimen could be easily obtained without any special skills, and surgical clearance could be verified intraoperatively. The ultrasonographic tumor thickness measurements corresponded well with those of histologic sections, with a consistency ratio of 91.4% to 98.2% (Pearson correlation coefficient = 0.981, P < .05).Conclusion: Intraoperative ultrasonography is a reliable method to objectively evaluate tumor thickness and surgical margin clearance.

Relationship of Synovial Tumor Necrosis Factor α and Interleukin 6 to Temporomandibular Disorder - Corrected Proof

Jeong Keun Lee, Young Sook Cho, Seung Il Song — 2009-12-23

Purpose: The purpose of this study was to elucidate the relationship of tumor necrosis factor α (TNF-α) and interleukin 6 (IL-6) to temporomandibular disorder with clinical symptoms such as pain, joint sounds, and mouth opening limitation by analysis of the level of these molecules in the synovial fluid.Patients and Methods: Twenty-four patients with chief complaints of pain, mouth opening limitation, and clicking sounds were selected as the experimental group and compared with 5 healthy subjects. After joint lavage with arthrocentesis, diluted synovial fluid was collected and enzyme-linked immunosorbent assay was done for analysis of TNF-α and IL-6 in 24 experimental patients and 5 healthy subjects.Results: The synovial levels of TNF-α and IL-6 were elevated in the experimental group compared with the healthy control group, but no significant correlation was established. The synovial levels of TNF-α and IL-6 were elevated in the acute pain group compared with the chronic pain group, but no significant correlation was established.Conclusion: In our analysis of 2 proinflammatory cytokines, TNF-α and IL-6, in the synovial fluid of temporomandibular disorder patients with symptoms of pain, mouth opening limitation, and clicking, both were elevated without statistical significance.

Anisocoria After Open Reduction and Internal Fixation of a Mandible Fracture Under General Anesthesia: A Case Report - Corrected Proof

Marcin Jarmoc, Kalpakam Shastri, Fred Davis — 2009-12-21

Anisocoria is an alarming finding, especially on emergence from general anesthesia. It can be a sign of a significant intracranial injury, which requires immediate treatment. The proper diagnosis of the unilateral mydriasis associated with general anesthesia is complicated by unresponsiveness or decreased responsiveness of the patient due to anesthetic agents. When anisocoria is observed, several possibilities should be considered as to the etiology. Cerebrovascular injury such as a ruptured aneurysm, cerebral trauma, a mass lesion, direct trauma to the globe, inadvertent deposition of mydriatic medications, deposition of local anesthetic into the eye, edema, and Adie pupil should all be in the differential diagnosis. We present the case of a healthy 26-year-old woman who presented with a mandible fracture requiring open reduction and was found to have a dilated left pupil on emergence from general anesthesia.

Bioabsorbable Plates and Screws for Fixation of Mandibulotomies in Ablative Oral Cancer Surgery - Corrected Proof

2009-12-17

Purpose: The use of bioabsorbable self-reinforced poly(l/dl)lactide 70/30 (SR-PLDLA) miniplates and screws could offer many benefits compared with conventional metallic devices for fixation of access osteotomies in oral cancer surgery. The material neither interferes with imaging nor with postoperative radiotherapy. The plates and screws do not need to be removed. The number of operations can be diminished and rehabilitation with dental implants shortened. The purpose of the present study was to report our experience with bioabsorbable osteosynthesis in the fixation of access osteotomies of the mandible.Patients and Methods: A total of 15 patients (11 men and 4 women, mean age 63.1 years) were enrolled in the present study. All patients had oral squamous cell carcinoma. Three patients developed tumor recurrence, 2 of whom had previously undergone radiotherapy. Nine patients had radiotherapy scheduled postoperatively. The osteotomies were a straight-line cut and were situated medially or paramedially. For fixation, SR-PLDLA miniplates and screws (Biosorb 2.0 and 2.4 systems) were used without any maxillomandibular fixation.Results: The follow-up ranged from 0.3 to 7.1 years (median 3.5). No problems were encountered during the operation. One patient required reoperation owing to failure in fixation. Twelve osteotomy lines (80%) were clinically stable; radiologically, 6 were totally and 3 partly consolidated. During follow-up, 6 nonunions were radiographically noted, 3 of which were clinically stable.Conclusions: Because of the high incidence of radiologic nonunion, bioabsorbable devices should not yet be used for fixation of access osteotomies in cancer surgery.

Facial Artery Pseudoaneurysm Following Surgical Removal of a Mandibular Molar - Corrected Proof

Farshid Rayati, Hossein Parsa, Pooria Fallah Abed, Tuba Karagah — 2009-12-17

Arterial vascular injuries after dental extractions are very rare, but they may be associated with significant morbidity and mortality. Aneurysms are defined as abnormal and localized dilations of blood vessel walls. These lesions can be caused by trauma or may result from a weakened vessel wall with preservation of all vascular layers. The former type is known as a false aneurysm, and the latter is regarded as a true aneurysm. False arterial aneurysms or pseudoaneurysms usually produce a pulsating hematoma and develop after rupture of an arterial wall and extravasation of blood into surrounding tissues. Perivascular connective tissues form the sac of false aneurysms, which may gradually expand and rupture, leading to life-threatening hemorrhage. Surgical removal of impacted third molars can damage the facial artery wall and produce pseudoaneurysms due to retention of effused blood in surrounding tissues. Color Doppler ultrasonography plays a key role in the management of traumatic vascular lesions by locating the aneurysm sac and establishing its relation to the adjacent arteries.

Maxillary Aseptic Necrosis After Le Fort I Osteotomy: A Case Report and Literature Review - Corrected Proof

2009-12-17

Maxillofacial orthopedic surgery is a safe, predictable, and stable procedure. The number of life-threatening complications associated with this surgery appears to be very small. Other minor intraoperative and perioperative complications have been reported, but their incidence is considered low.

Lower Extremity Compartment Syndrome Associated With Hypotensive General Anesthesia for Orthognathic Surgery: A Case Report and Review of the Disease - Corrected Proof

Tyson J. Teeples, David J. Rallis, Kevin L. Rieck, Christopher F. Viozzi — 2009-12-14

Compartment syndrome (CS) is a process that occurs when pressure increases within closed, inelastic musculofascial compartments. A vicious cycle begins as reperfusion follows ischemia, leading to edema. Edema in a fixed space can result in pressures elevating above capillary pressure; arterial inflow and venous outflow are thus diminished. This process is progressive, with worsening ischemia, further pressure increase, halted outflow, and eventually, when the metabolic demands of the tissue are no longer met, rhabdomyolysis and necrosis.

A Rare Case of IgG4-Related Sclerosing Disease of the Maxillary Sinus Associated With Bone Destruction - Corrected Proof

Clarence Pace, Sean Ward — 2009-12-14

A 73-year-old man presented to the accident and casualty department with a 2-week history of increasing right-sided facial swelling. This was associated with a low-grade fever. Examination confirmed a 6-cm diameter swelling over the malar prominence. The overlying skin was normal and there was no paresthesia in the infraorbital nerve distribution. No trismus was evident. Intraoral examination revealed fullness in the upper buccal sulcus with almost complete effacement. Otherwise the examination was unremarkable. He was medically fit apart from benign prostatic hyperplasia.

Mineralization of the Stylohyoid Ligament Complex in a Jordanian Sample: A Clinicoradiographic Study - Corrected Proof

Taiseer Hussain Al-Khateeb, Tareq Ma'mon al Dajani, Ghaida Ahmad Al Jamal — 2009-12-14

Purpose: To record the prevalence of anatomic variations and the associated symptoms of mineralized stylohyoid complex (MSHC) in a Jordanian sample, and to investigate the possible factors responsible for mineralization.Patients and Methods: This study was conducted at the Dental Teaching Clinics of Jordan University of Science and Technology in patients referred for panoramic radiographs. The MSHC, on either side of panoramic radiographs, was mapped out on tracing paper, the length directly measured, and the true length calculated. The true length of the MSHC was used to classify every side into short, long, or elongated, and the radiographic type of long and elongated MSHCs was determined as elongated, pseudoarticulated, or segmented.Results: A total of 867 MSHCs were traced with an overall average length of the 23.1 mm. The most frequent class and type were long (53.3%) and elongated (41.6%), respectively. There was a significantly (P < .05) progressive increase in the length of the MSHC. The frequency of both of elongated and pseudoarticulated types increased and that of the segmented type decreased with aging. The mean length of the MSHC for patients with a history of tonsillectomy (26.29 mm) was significantly higher (P < .05) than its value in patients without a history of tonsillectomy (22.70). There was also a significantly (P < .05) progressive increase in the length of the MSHC as the age when tonsillectomy was performed increased. The mean length of the MSHC for cases with history of recurrent tonsillitis (6.99 mm) was significantly higher (P < .05) than for those without (2.42 mm). The mean length of the MSHC for patients with a history of head-and-neck or whole-body trauma was not statistically significantly different (P > .05) from the value for the nontraumatized patients. The mean length of the MSHC for patients with arthritis (27.70 mm) was significantly higher (P < .05) than that in patients without arthritis (22.53 mm). The highest frequency of MSHC palpated in the tonsillar fossa was significantly (P < .05) related to the elongated class (44; 64.8%) and type (100; 52%). The mean length of the MSHC was significantly higher in patients who reported having 4 symptoms, but only 1 symptom had a significant association with the type of MSHC.Conclusion: History of recurrent tonsillitis has a major effect on the true length of the MSHC, and trauma is not a significant factor for the development of longer MSHC.

Extraneural Soft Tissue Perineurioma of the Oral Mucosa - Corrected Proof

2009-12-14

The perineurium is a specialized protective barrier for peripheral nerves situated between the endoneurium and epineurium. It is composed of perineurial cells arranged in one or more concentric layers immersed in collagen fibers and extracellular matrix, and surrounded by a continuous basement membrane. Perineurial cells may occur as a minor population in several neoplastic and hyperplastic lesions of the peripheral nerve sheath or as the main neoplastic proliferation of perineurioma. There are 2 variants of perineuriomas displaying distinctive clinicopathological features, the intraneural and the extraneural, the latter including soft-tissue, sclerosing, and reticular forms.

In Vitro Biomechanical Evaluation of the Use of Conventional and Locking Miniplate/Screw Systems for Sagittal Split Ramus Osteotomy - Corrected Proof

2009-12-07

Purpose: The aim of this in vitro study was to assess the biomechanical stability of 9 different osteosynthesis methods after sagittal split ramus osteotomy by simulating the masticatory forces and using a 3-point biomechanical test method.Materials and Methods: Forty-five polyurethane hemimandibles with bone-like consistency were randomly assigned to 9 groups (n = 5) and subjected to sagittal split ramus osteotomy. After 4-mm advancement of the distal segment, the bone segments were fixed by different osteosynthesis methods using 2.0-mm miniplate/screw systems: group A, one 4-hole conventional straight miniplate; group B, one 4-hole locking straight miniplate; group C, one 4-hole conventional miniplate and one bicortical screw; group D, one 4-hole locking miniplate and 1 bicortical screw; group E, one 6-hole conventional straight miniplate; group F, one 6-hole locking straight miniplate; group G: two 4-hole conventional straight miniplates; group H, two 4-hole locking straight miniplates; and group I, 3 bicortical screws in an inverted-L pattern. All models were mounted on a base especially constructed for this purpose. Using a 3-point biomechanical test model, the hemimandibles were loaded in compressive strength in an Instron machine (Norwood, MA) until a 3-mm displacement occurred between segments vertically or horizontally. Data were analyzed by analysis of variance and Tukey test (α = 1%).Results: The multiparametric comparison of the groups showed a statistically significant difference (P < .01) between groups that used 2 miniplates (groups G and H), 1 miniplate and 1 bicortical screw (groups C and D), and only bicortical screws (group I) compared with groups that used only 1 miniplate with 2 screws per segment (groups A and B) and 3 screws per segment (groups E and F).Conclusion: The placement of 2.0-mm–diameter bicortical screws in the retromolar region, associated or not with conventional and locking miniplates with monocortical screws, promoted a better stabilization of bone segments. Locking miniplates presented a better performance in bone fixation in all groups.

Anophthalmic Orbit Syndrome: A New Free Tissue Transfer - Corrected Proof

Alessandro Baj, Francesco Laganà, Giada A. Beltramini, Aldo B. Giannì — 2009-12-07

The anophthalmic socket is the space posterior to the eyelids and anterior to the muscle cone. It is created after enucleation or evisceration of an eye. Numerous distant and local flaps, grafts, and osteotomies have been used to improve these deformities. We describe our experience with socket contraction between April 2001 and July 2008, during which 36 patients underwent surgical treatment for contracted sockets. The indications for surgery included moderate socket contraction in 14 patients, empty socket contraction in 13, and a malignant anophthalmic socket in 9. In the case of moderate socket contraction, the solution is to replace the lost tissue with a tissue that is as similar to the original as possible. Thus the best tissue with which to correct the mucosal deficit of the fornices is the oral mucosa. The best option by which to manage empty socket contraction is a dermis fat graft. In the case of a malignant socket, free tissue transfer is preferred. An adequate socket will safely retain an ocular prosthesis with a good cosmetic appearance. In patients who have undergone radiotherapy after enucleation of the eye, bony growth retardation and soft tissue retraction often cause severe hemifacial deformities. Moreover, so-called malignant contracture of the eye socket can develop at the site. Since 1990, different authors have proposed the use of free flaps to improve the results of this type of reconstruction, which remains challenging. The absence of an eye and the presence of hemifacial deformities should be treated with 2 goals in mind: 1) to obtain a socket sufficient to retain an ocular prosthesis and 2) to treat the consequences of an anophthalmic orbit by restoring equilibrium to the face. This report proposes the use of a costochondral graft associated with a free flap harvested from the contralateral auricle and mastoid area for a malignant contracted socket that developed after surgery and radiotherapy. The retroauricular area is an interesting donor site described by Washio and applied to eye contracture by Guyuron. These authors describe the application of a retroauricular flap as a pedicled flap. We propose using this flap harvested contralaterally for free tissue transfer in conjunction with a chondral graft to reduce the donor-site morbidity and obtain a stable cosmetic reconstruction.

Absolute Ethanol Sclerotherapy for Venous Malformations in the Face and Neck - Corrected Proof

Lixin Su, Xindong Fan, Lianzhou Zheng, Jiawei Zheng — 2009-12-07

Purpose: The purpose of the present study was to evaluate the outcomes of sclerotherapy using absolute ethanol for venous malformations in the face and neck.Patients and Methods: We treated 60 consecutive patients with venous malformations in the face and neck with sclerotherapy with absolute ethanol under the guidance of digital subtraction angiography. Magnetic resonance imaging was used to evaluate the clinical outcomes of sclerotherapy. Complications were also evaluated.Results: The duration of follow-up was a mean of 8 months (range, 3 to 22). Of the 60 patients, 22 were treated once and 38 were treated 2 to 18 times (mean 2.6 times/patient). The mean total volume of ethanol in 60 patients was 11.2 mL (range, 0.5 to 230 mL). Of the 60 patients, 56 had complete volume reduction and a marked response after treatment. No severe skin necrosis or permanent nerve damage occurred.Conclusion: Percutaneous sclerotherapy with absolute ethanol under the guidance of venography is a safe and effective treatment for venous malformations in the face and neck.

Midazolam More Effectively Suppresses Sympathetic Activations and Reduces Stress Feelings During Mental Arithmetic Task Than Propofol - Corrected Proof

Rie Tsugayasu, Toshiyuki Handa, Yuzuru Kaneko, Tatsuya Ichinohe — 2009-12-04

Purpose: The aim of the present study was to examine the effect of intravenous midazolam and propofol sedation on autonomic nervous activities during psychological stress, and whether these results are associated with changes in subjective stress feelings.Materials and Methods: Seven healthy male volunteers were included in a randomized crossover manner. The heart rate (HR), HR variability, arterial oxygen saturation, and bispectral index value were continuously monitored. A mental arithmetic task for 7 minutes was given with or without intravenous sedation with midazolam or propofol. A bispectral index value of 75 to 85 and an Observer's Assessment of Alertness/Sedation score of 4 were the targeted sedation level in both groups. HR variability was assessed using the power spectral analysis (low-frequency [LF] and high-frequency [HF] components and LF/HF ratio). The faces anxiety scale was used to grade their stress feelings after each mental arithmetic task.Results: During the mental arithmetic task with intravenous sedation, no differences were found in the bispectral index values, arterial oxygen saturation, or the results of the mental arithmetic task between the 2 groups. The HR, LF/HF ratio, and normalized unit LF increased, and the normalized unit HF decreased in both groups. However, the percentage of changes in LF/HF ratio, normalized unit LF, and normalized unit HF were smaller in the midazolam group. In addition, the reduction in faces anxiety scale was greater in the midazolam group.Conclusions: These results suggest that midazolam more effectively suppresses sympathetic nervous activation and reduces subjective stress feelings during a mental arithmetic task than propofol.

Extranodal Natural Killer T-Cell Lymphoma, Nasal Type, With Minimal Osseous Involvement: Report of a Case and Literature Review - Corrected Proof

2009-12-04

Extranodal natural killer/T-cell lymphoma (ENKTCL) is a rare form of Epstein-Barr virus (EBV)–associated non-Hodgkin lymphoma (NHL). The nose and paranasal sinuses are the most commonly reported sites of initial involvement. ENKTCL is reported most frequently in East Asian populations and is notably rare in Western populations. The purposes of this case report are to describe an atypical presentation of ENKTCL involving primarily the soft tissues of the midface and to highlight the vigilance required in diagnosing this cause of nonresolving facial swelling.

Anaplastic Large Cell Lymphoma: Case Report and Literature Review - Corrected Proof

2009-12-03

This report presents a case of anaplastic large cell lymphoma (ALCL; null cell type) in a Nigerian. ALCL is a well-characterized disorder, but very rare, and arriving at a definitive diagnosis presented a challenge. The use of immunophenotyping and cytogenetic characterization helped resolve the diagnostic confusion. However, it was too late to help the patient once the confusion had been eliminated. This case reflects the peculiar diagnostic challenges and limitations in a resource-scarce environment typical of most rural and semiurban communities in sub-Saharan Africa.

Caliber-Persistent Labial Artery: Diagnosis and Treatment—Case Report - Corrected Proof

M.A.J. Michael J. Piccione, C.O.L. Albert M. Manganaro, C.O.L. Jeffrey S. Almony — 2009-12-03

In 1884 Gallard first described the caliber-persistent artery in 3 patients who died of a gastric hemorrhage that was within the submucosa. The caliber-persistent labial artery (CPLA) was first described as a prominent inferior labial artery in 1973 by Howell and Freeman. The CPLA often arises from the inferior labial artery that penetrates submucosally without arborizing and without a reduction in diameter. Howell and Freeman showed the incidence of a CPLA with tumefaction to be 3% in the upper and lower lips among a total of 1,034 patients aged 35 years or older.

Calvarial Reshaping Using Bifocal Bidirectional Transport Distraction Osteogenesis - Corrected Proof

2009-12-03

Purpose: The aim of this study is to assess 3-dimensional reconstruction of cranial defects by use of bifocal bidirectional transport distraction osteogenesis (BBTDO).Materials and Methods: This study was performed on 8 sheep, divided into a control group (n = 3) and treatment group (n = 5). Full-thickness cranial defects (50 × 40 mm) were created on calvaria. In the control group only the skin was closed. In the treatment group BBTDO was performed. Distraction was performed with a custom-made distraction device with a transport segment of 40 × 20 mm. After a 5-day period of latency, distraction was applied to the transport segment. During the first 20 days of distraction, the transport segment was distracted 1 mm in the forward direction and 0.5 mm in the upward direction. After the next 20 days of distraction, the transport segment was distracted 1 mm forward and 0.5 downward. After a total of 40 days' distraction, a 30-day consolidation period was applied. Macroscopic, radiologic (computed tomography with volume measurements), and histologic evaluations were done.Results: No major complications were seen during the whole study period. In the control group the bone defects remained unhealed at the end of the study period. The same-sized defects in the treatment group healed with a convexity like the calvaria. Preoperative and postoperative cranial volume measurements of the treatment group animals showed an increase in cranial volume (P < .05). Histologic evaluation showed inductive bone regeneration and mature bone structure development within the distraction zone.Conclusion: The BBTDO is an effective and safe technique for 3-dimensional closure of cranial defects.

Prevalence of Temporomandibular Disorders in Patients With Gastroesophageal Reflux Disease: A Case Controlled Study - Corrected Proof

Tareq M. Gharaibeh, Khaled Jadallah, Fuad Abul Jadayel — 2009-12-03

Purpose: The present study estimated the prevalence of temporomandibular disorders (TMDs) in patients with gastroesophageal reflux disease (GERD).Patients and Methods: A study group consisting of 60 adult patients (34 women and 26 men) diagnosed with GERD was matched by age and gender to a control group of 60 patients without any signs or symptoms of GERD. The diagnosis of TMD was established using the Research Diagnostic Criteria for Temporomandibular Disorders.Results: Of the 60 patients in the study group, 22 (36.6%) had TMD compared with 11 (18.3%) in the control group (P = .025). Most patients with TMD in both groups were diagnosed with myofascial pain: 19 (31.7%) in the study group versus 9 (15%) in the control group (P = .031).Conclusions: The increased TMD prevalence in patients with GERD should be explored further to better characterize the association between TMD and GERD. The physicians treating the 2 disorders should consider the clinical implications of this association.

Simultaneous Correction of Bilateral Temporomandibular Joint Ankylosis With Mandibular Micrognathia Using Internal Distraction Osteogenesis and 3-Dimensional Craniomaxillofacial Models - Corrected Proof

Ping Feiyun, Liu Wei, Chen Jun, Xu Xin, Shi Zhuojin, Yan Fengguo — 2009-12-03

Purpose: The present study evaluated the simultaneous correction of bilateral temporomandibular joint ankylosis with mandibular micrognathia using internal distraction osteogenesis (DO) with the help of a 3-dimensional craniomaxillofacial model technique.Materials and Methods: A total of 16 patients (age 18 to 43 years) with bilateral temporomandibular joint ankylosis and mandibular micrognathia were included in the present study. Obstructive sleep apnea and hypopnea syndrome was diagnosed in all patients preoperatively. Three-dimensional craniomaxillofacial models of the 16 patients were constructed using computed tomography and a rapid prototype technique. Simulation surgery and individual internal DO was performed on the models. The treatment included simultaneous DO of the mandibular body and transport DO for temporomandibular joint arthroplasty. The distraction was started on the seventh day after surgery. The distraction rate was 0.8 mm/day. The patients began active mouth opening postoperatively. Distracters were kept in place for 4 months after distraction completion and then removed. Polysomnography, cephalometry, and computed tomography were performed at 6 months postoperatively.Results: The obstructive sleep apnea and hypopnea syndrome was cured, and the micrognathia was corrected in all patients. The average mouth opening increased from 4.6 mm preoperatively to 33.5 mm postoperatively. The average range of the sella-nasion-supramental angle increased from 68.7° preoperatively to 77.6° postoperatively. Bone formation in the distraction gaps was observed. The follow-up period was 29.7 months (range 6 to 52). No complications or recurrence of temporomandibular joint ankylosis or micrognathia occurred in any patient during the follow-up period.Conclusions: Bilateral temporomandibular joint ankylosis accompanied by mandibular micrognathia and obstructive sleep apnea and hypopnea syndrome can be corrected effectively by simultaneous internal DO. The application of preoperative simulation surgery using 3-dimensional craniomaxillofacial model has many advantages for planning the surgical method and precise operation. Our preliminary results have shown that it is a safe, effective, and feasible technique.

Microsurgical Upper Lip Replantation: A Case Report - Corrected Proof

Alessandro Baj, Giada A. Beltramini, Francesco Laganà, Aldo B. Giannì — 2009-12-03

Lip amputation is rare, and systematic microsurgical replantation is necessary to achieve morphofunctional restoration of the traumatized structure in a single surgical operation. We describe a case of right hemilip and labial filter avulsion, resulting from a dog bite. The amputated section was revascularized by arterial microanastomosis, whereas no venous anastomosis was performed, because no venous blood vessel was identified. Venous drainage was obtained through the postoperative application of leeches together with anticoagulant and antibiotic therapy. The esthetic and functional results were good in terms of form, color, scarring, and the restoration of lip function and sensitivity.

A Slow-Growing Palatal Mass: A Challenging Differential Diagnosis - Corrected Proof

2009-12-03

Purpose: The purpose of this article is to present an additional case of clear cell carcinoma, not otherwise specified (CCC-NOS) and to review in detail the microscopic differential diagnosis of clear cell neoplasms, which encompasses a broad range of possibilities.Patient and Methods: A 41-year-old man presented with a slow-growing palatal mass. Intraoral examination revealed a submucosal mass on the right side of the hard palate. Conventional radiographs, computed tomography (CT) and magnetic resonance (MR) imaging were analyzed. A microscopic examination of an incisional biopsy specimen was performed. Histochemical and immunohistochemical studies were carried out in order to establish the microscopic differential diagnosis.Results: Conventional radiographs showed an osteolytic lesion in the premolar area as well as tooth resorption in the right second molar. CT and MR imaging showed a neoplasm extending from the premolars to the tuberosity region on the right side of the maxilla and the resorption of the ipsilateral maxillary sinus floor. The microscopic examination revealed a monomorphous population of polygonal and round cells with abundant and clear cytoplasm, arranged in nests and cords. Clear cells were negative for mucicarmine and periodic acid-Schiff. The immunohistochemical study showed that the neoplastic clear cells were positive for cytokeratin 8 and 7, but negative for S100, vimentin, and smooth muscle actin. On jointly considering the microscopic, histochemical, and immunohistochemical features, the diagnosis of CCC-NOS was established. Using differential diagnosis as a basis, epithelial myoepithelial carcinoma, myoepithelial carcinoma, mucoepidermoid carcinoma, acinic cell carcinoma, oncocytoma (clear cell variant), malignant sebaceous tumors, and metastasis from renal carcinoma were all ruled out. The patient underwent hemimaxillarectomy and adjuvant radiotherapy.Conclusion: Determining CCC-NOS and distinguishing this tumor from other clear cell neoplasms is crucial to establishing the appropriate diagnosis and therapeutic approach.