International Journal of Oral & Maxillofacial Surgery

Editorial Board

2010-03-01

Clinical use of botulinum toxins in oral and maxillofacial surgery

O.W. Majid — 2009-12-03

Botulinum toxin (BTX) is a bacterial toxin that could be used as a medicine. Clinical applications of BTX have been expanding over the last 30 years and novel applications reported. Its mechanism of inhibiting acetylcholine release at neuromuscular junctions following local injection is unique for the treatment of facial wrinkles. Other dose-dependent anti-neuroinflammatory effects and vascular modulating properties have extended its spectrum of applications. Conditions such as temporomandibular joint disorders, sialorrhea, headache and neuropathic facial pain, muscle movement disorders, and facial nerve palsy could also be treated with this drug. Further applications of BTX are likely to be developed. This paper reviews the established and emerging applications of BTX in the field of oral and maxillofacial surgery. An overview of the pharmacology, toxicity and preparations of the agent is given.

Detecting early oral cancer: narrowband imaging system observation of the oral mucosa microvasculature

2010-02-25

Abstract: The aim of this study was to analyze and describe the intrapapillary capillary loops (IPCL), which are a feature of early oral neoplastic lesions, using a narrowband imaging (NBI) system. Forty-one patients (26 men, 15 women; mean age, 52.34 years; range, 23–83 years) presenting with non-neoplastic or neoplastic lesions, and normal cases, were examined using the prototype Evis Lucera Spectrum (Olympus Co.). The images were analyzed and an IPCL classification was devised. All normal cases (n=10) had regularly distributed capillary loops of the same shape (type I). Non-neoplastic lesions (n=8) had mild changes of the capillary loops (types II and III) and neoplastic lesions (n=23) were irregularly distributed and had several loop shapes (types III and IV). The microvascular organization of non-neoplastic lesions was notably different from that of neoplastic lesions. A brownish area was found in five cases of early carcinoma. The narrowband imaging system is a potential approach for clinically analyzing microvascular organization and IPCL. It could be useful for diagnosing oral squamous cell carcinoma at an earlier stage and for determining the margin of resection.

Initial counselling for cleft lip and palate: Parents’ evaluation, needs and expectations

J. Kuttenberger, J.N. Ohmer, E. Polska — 2010-01-15

Abstract: During the first counselling after the birth of a child with cleft lip and palate (CLP) information about the malformation should be delivered and a long-standing relationship between the cleft team and the affected family must be established. The present study was conducted to evaluate the parents’ experiences, needs and expectations with this first consultation. A questionnaire was sent to 105 parents at the cleft clinic, which could be answered anonymously. It collected demographic data, data on the parents’ pre-existing level of information and the parents’ assessment of the counselling at the cleft centre. Seventy percent of the questionnaires were returned. In 16% the clefts were diagnosed prenatally, in 32% there were relatives with clefts. Seventy-one percent of the parents received detailed counselling, 89% of which occurred in the first week. The parents requested that information about surgery (80%), feeding the child (63%) and the aetiology of clefts (44%) should be given. The quality of the consultation was rated very good or good by 87% of families. This study confirms the importance of initial counselling for CLP. The exceptional psychological situation of the family has to be considered and a close collaboration between cleft centre and maternity hospitals is mandatory.

Prognosis for craniofacial fibrous dysplasia after incomplete resection: age and serum alkaline phosphatase

B.Y. Park, Y.W. Cheon, Y.O. Kim, N.S. Pae, W.J. Lee — 2010-01-18

Abstract: Complete resection is usually impossible for fibrous dysplasia (FD) involving the cranial base. Incomplete resection could be followed by regrowth of FD, but there is no method for indicating disease progress. Serum alkaline phosphatase (ALP) is significantly high in patients with FD. The authors investigate the relationship between ALP, progress of FD, and age at surgery. 18 patients with craniofacial FD were separated into 3 groups: Group A, complete resection; Group B, incomplete resection followed by regrowth of FD; and Group C, incomplete resection but no regrowth of FD. Medical records and CT scans were reviewed retrospectively. ALP levels were obtained preoperatively, postoperatively and every year during follow-up. The relation between ALP and regrowth and that between age at surgery and regrowth were investigated. There was no recurrence in Group A (n=4). Regrowth in Group B (n=7) was preceded by an abrupt increase in ALP. In Group C (n=7), no regrowth was observed and ALP was maintained within the normal range. 6 patients (85%) in Group B and 2 (28%) in Group C were under 17 years old. The results revealed that the level of postoperative serum ALP could be a reliable marker for predicting the progress of craniofacial FD.

Augmentation of the atrophic edentulous mandible by a bilateral two-step osteotomy with autogenous bone graft to place osseointegrated dental implants

S. Pelo, R. Boniello, A. Moro, G. Gasparini, P.F. Amoroso — 2009-12-18

Abstract: Extensive resorption of the mandible increases the interarch space and rehabilitation with traditional dentures is often unsatisfactory due to the superficialization of intraoral muscles. A study of 19 patients who underwent augmentation of an atrophic mandible using a bilateral two-step osteotomy and interpositional bone graft technique is presented. Three horizontal bone cuts (one in the intraforamina and two in the molar region) were made and jointed together by two short vertical bone cuts mesialy to the mental nerve. The cranial fragment was lifted and the iliac bone graft was interposed recreating the correct intermaxillary relationship. A broad vascular pedicle was maintained during surgery, ensuring nutrition from the lingual side, essential to reduce resorption of the bone graft and cranial fragment. 141 Biomet 3i Osseotite® implants were placed. Patients were rehabilitated with a full-arch implant-supported fixed prosthesis or an implant-supported overdenture. This clinical study describes the resorption process over a 4 year follow-up. 3 of 19 suffered from persistent neurosensitive disturbances. In conclusion, bilateral two-step osteotomy in association with interpositional bone graft is a reliable surgical means to recreate the anatomical morphology of the mandible.

Salivary gland neoplasms in oral and maxillofacial regions: a 23-year retrospective study of 6982 cases in an eastern Chinese population

Z. Tian, L. Li, L. Wang, Y. Hu, J. Li — 2009-12-01

Abstract: There is little information in the English-language literature about the epidemiology of salivary gland neoplasms in the eastern Chinese population. A large retrospective study (6982 primary salivary tumors during 23 years) was carried out to investigate the clinicopathological features (tumor location, patient sex and age) of these tumors in this population. 3593 tumors were in males and 3389 in females. Pleomorphic adenoma (69%) was the most common tumor and 20% were located in minor glands. 92% of Warthin's tumors occurred in males. Malignant tumors were predominantly adenoid cystic carcinoma (30%) and mucoepidermoid carcinoma (30%). Incidences of lymphoepithelial carcinomas (5%) and polymorphous low-grade adenocarcinoma (1%) of malignant tumors were identified. 28% of tumors originated from minor glands. Most findings were similar to those in the literature, with some variations. The salivary tumors slightly predominated in males. Relatively higher incidences of minor gland tumors and specifically of pleomorphic adenoma in minor glands were noted. Adenoid cystic carcinoma and mucoepidermoid carcinoma constituted the most common malignancies. There was a high incidence of lymphoepithelial carcinomas but a low incidence of polymorphous low-grade adenocarcinoma. The historical significant male predominance of Warthin's tumor was confirmed.

Parapharyngeal space tumors: surgical approaches in a series of 13 cases

N. Papadogeorgakis, V. Petsinis, L. Goutzanis, G. Kostakis, C. Alexandridis — 2009-12-14

Abstract: Tumors originating in the parapharyngeal space are rare; they comprise approximately 0.5% of head and neck tumors. Most (70–80%) are benign and the most frequent origins are salivary and neurogenic. The aim of this study is to present the surgical procedures used for the treatment of 13 patients with parapharyngeal space tumors; 11 of them were suffering from benign tumors (the most frequent being pleomorphic adenoma; 8 cases) and 2 from malignant lesions. The following surgical approaches were used: intraoral (2 cases), transcervical (4 cases) and transmandibular (7 cases) with different types of mandible osteotomies. The type of surgical approach was dictated by the type of the lesion (malignant or benign), the exact location, the size, the vascularity and the relation of the tumor to the neck neurovascular bundle. In all cases the selected surgical approach allowed the complete resection of the tumor, obtaining clear margins in cases of malignancy, without adding to the patient's preoperative morbidity. It was concluded that the surgical approach to the parapharyngeal space tumors must be adjusted to the tumor characteristics and be as wide is necessary to achieve its complete removal with safety.

Surgical management of bisphosphonate induced osteonecrosis of the jaws

R.A. Williamson — 2009-12-16

Abstract: Recent literature contains numerous articles on osteonecrosis of the jaws (ONJ) associated with bisphosphonate treatment (BPT), with most advocating a conservative approach to management. A prospective study was designed to review the surgical management of cases of ONJ that did not respond to conservative management. Forty patients, referred with ONJ that did not respond to conservative management, were treated surgically and followed up for 6 months to 4 years. Four patients were taking i.v. BPT as part of their bone cancer management and 16 were taking oral BPT for osteoporosis. The surgical management of ONJ involved antibiotic therapy, surgical debridement of all necrotic bone and tension-free primary closure. All 40 cases healed uneventfully with no wound breakdown during follow-up. Most of the literature supports the conservative management of ONJ, but the condition leaves the patient debilitated. Many cases do not respond to conservative management and the infection and bone destruction is progressive. The conservative management of ONJ is to be supported, but this prospective study has shown that those cases that do not respond may be managed surgically. It should be recognized that while the results of this paper are encouraging, some cases will be resistant to all treatments.

Incidence of venous thromboembolism in oral and maxillofacial surgery: a retrospective analysis

2009-12-17

Abstract: This study retrospectively investigates the incidence and risk factors for venous thromboembolism (VTE) in patients undergoing maxillofacial surgery. Data were obtained from patients treated between January 2005 and June 2006. Patients’ records were reviewed for complaints and information relating to deep venous thrombosis (DVT) and pulmonary embolism (PE). All patients completed a questionnaire on complaints relating to DVT and PE. The patients were classified according to risk and the incidence of reported DVT and PE was calculated. The study population comprised 411 patients with a mean age of 32 (± 17) years. The median postoperative follow-up period was 53 (23–639) days. None of the patients received thromboembolism prophylaxis. The incidence of VTE in the study group was 0.5%. Logistic regression analysis demonstrated a relationship between body mass index and hospital stay with thromboembolism (p<0.05). Patients undergoing pre-implant surgery with bone graft proved to be at risk (p=0.07). The incidence of VTE in oral and maxillofacial surgery seems to be low, but thromboembolism prophylaxis may be justified in patients with clear potential risk factors.

The effect of a single dose of bupivacaine on donor site pain after anterior iliac crest bone harvesting

2009-12-03

Abstract: Transplants from the anterior iliac crest are used for most reconstructive procedures in cranio-maxillofacial surgery. The advantages are easy accessibility, the ability to work in two teams and the amount of corticocancellous bone available; disadvantages are postoperative pain and gait disturbances. To reduce donor-site pain, the effect of a single dose of bupivacaine (10 cc of 2.5mg/cc with 1:80.000 epinephrine) was studied. 200 consecutive patients, who underwent anterior iliac crest bone harvesting for reconstructive procedures, were randomly divided into those receiving bupivacaine and those not. They completed a standardized questionnaire. Patients scored the intensity of the pain and difficulties walking at different times with a visual analogue scale. They recorded analgesics used. 98 questionnaires were eligible for analysis. No differences between the bupivacaine and the control group were detected for postoperative pain and gait disturbance. There is no support for administration of a single dose of bupivacaine to reduce pain in the first postoperative days. The surface area of the removed bone had a significant influence on pain and walking; pain is related to the local osseous damage or periosteal stripping rather than to the length of incision or the operation time.

Effects of bone morphogenetic protein-2 on proliferation and angiogenesis in oral squamous cell carcinoma

Q. Gao, W. Tong, J.S. Luria, Z. Wang, B. Nussenbaum, P.H. Krebsbach — 2010-01-14

Abstract: Experimental data and limited patient experience suggest that rhBMP-2 can be used to regenerate bone in acquired segmental defects of the mandible. Most of these defects are caused by resection of oral squamous cell carcinoma (OSCC) and the biologic effects of rhBMP-2 on these carcinoma cells are unknown. The objective of this study was to determine whether rhBMP-2 produces adverse effects on proliferation and angiogenesis in OSCC, two biologic processes critical to tumor formation. In vitro studies included treating OSCC cells with rhBMP-2 or an adenoviral vector containing the cDNA for BMP-2. In vivo studies involved co-transplantation of OSCC cells with bone marrow stromal cells genetically modified to over express BMP-2, to mimic a clinically relevant scenario for regenerating bone using cell-based therapy in a wound containing microscopic residual disease. Proliferation, as measured by a MTT assay in vitro and tumor growth in vivo was not affected by treatment with BMP-2. Angiogenesis, measured by secretion of the proangiogenic molecules VEGF and IL-8 in vitro and microvessel density in vivo, was not affected. Exposure of OSCC cells to BMP-2 does not stimulate proliferation or angiogenesis. Further studies are needed before using rhBMP-2 for bone tissue engineering in oral cancer-related defects.

Distribution of Small Integrin-Binding LIgand, N-linked Glycoproteins (SIBLING) in the condylar cartilage of rat mandible

2010-01-25

Abstract: The Small Integrin-Binding LIgand, N-linked Glycoprotein (SIBLING) family is one category of non-collagenous proteins closely related to osteogenesis. In this study, the authors systematically evaluated the presence and distribution of four SIBLING family members, dentin sialophosphoprotein (DSPP), dentin matrix protein 1 (DMP1), bone sialoprotein (BSP) and osteopontin (OPN), in rat mandibular condylar cartilage using protein chemistry and immunohistochemistry. For protein chemistry, SIBLING proteins in the dissected condylar cartilage were extracted with 4M guanidium–HCl, separated by ion-exchange chromatography, and analyzed by Western immunoblotting. Immunohistochemistry was employed to assess the distribution of these four SIBLING proteins in the condylar cartilage of 2-, 5- and 8-week-old rats. Results from both approaches showed that all four members are expressed in the condylar cartilage. DSPP, unlike that observed in dentin and bone, exists as a full-length form (uncleaved) in the condylar cartilage. The NH2-terminal fragment of DMP1 is mainly detected in the matrix of the cartilage while the COOH-terminal fragment is primarily localized in the nuclei of cells in the chondroblastic and hypertrophic layers. The data obtained in this investigation provide clues about the potential roles of these SIBLING proteins in chondrogenesis.

The influence of expansion on intraoperative bone blood flow in multisegmental maxillary osteotomies: an experimental study

W.B. Kretschmer, G. Baciut, C. Dinu, M. Baciut, I. Barbur, A. Muste, K. Dietz — 2010-01-25

Abstract: The aim of the presented study was to investigate the effect of maxillary expansion in multisegmental Le Fort I osteotomies on bone blood flow. Five sheep underwent a three-piece total maxillary osteotomy. Bone blood flow was measured intraoperatively by laser Doppler flowmetry in the premaxilla, the lateral segments and the mandible before osteotomy, after osteotomy and segmentation as well as after 4mm, 8mm and 12mm expansion with a Hyrax screw. A significant reduction in blood flow was seen after osteotomy and segmentation with a factor of 3.10 and between 4mm and 8mm expansion with a factor of 1.81. No significant differences could be found between 0mm and 4mm widening or between 8mm and 12mm widening. These results suggest that expansion of more than 4mm in multisegmental osteotomies enhances the risk of avascular sequelae. As greater maxillary widening has been carried out in many cases without avascular complications, further research on additional factors, influencing the recovery of perfusion, is needed.

A technique for functional and aesthetic reconstruction of the oral commissure and buccal mucosa

A. Jhamb, S. Mohanty — 2009-12-17

Abstract: Oral mucosal lesions such as hyperkeratosis can enlarge and involve adjacent anatomic structures. Surgical treatment may cause significant morbidity in terms of loss of function due to scarring and compromised aesthetics due to failure to restore the original muscle anatomy and overlying soft tissue. The authors present a case of hyperkeratosis of the oral commissure and buccal mucosa, which was successfully reconstructed by using vermilion myomucosal flap and A-T advancement.

Intraoral vertical ramus osteotomy: a simple method to prevent medial trapping of the proximal fragment

D. Blinder, O. Peleg, T. Yoffe, S. Taicher — 2010-02-03

Abstract: Intraoral vertical ramus osteotomy (IVRO) is a useful surgical procedure for mandibular setback in patients with mandibular prognathism or mandibular asymmetry. IVRO has some intraoperative complications, such as the medial trapping of the proximal segment. Several techniques have been described to overcome this problem, but none can prevent it. This technical report describes a method that prevents the medial trapping of the proximal segment during IVRO.

A complication of Le Fort I osteotomy

A.A. Bhaskaran, D.J. Courtney, P. Anand, S.A. Harding — 2009-11-09

Abstract: Le Fort I osteotomy is a routine procedure for oral and maxillofacial surgeons. Following advances in instrumentation and anaesthesia, it is usually carried out safely as an elective procedure in hospitals with no adverse complications. Life-threatening complications are rare although the operation is performed in an area with an extensive vascular supply. The authors report a case of Le Fort I osteotomy that resulted in an unusual complication of cerebrospinal fluid leak.

Intra-oral removal of ectopic third molar in the mandibular condyle

K.S. Gadre, P. Waknis — 2009-11-05

Abstract: The surgical removal of impacted third molars is the most common procedure performed by maxillofacial surgeons. Only a few cases of ectopic third molars in the condyle have been reported. Most have been treated using an extra-oral or endoscopic approach. The management of this condition using an intra-oral approach (removal of this tooth and maintaining the anatomy of the condyle) is described in two case reports.

Clear cell myoepithelial carcinoma of minor salivary gland: a case report

S. Yang, M. Zeng, J. Zhang, X. Chen — 2009-11-26

Abstract: Myoepithelial carcinoma with predominantly clear cell morphology is rare. A review of the literature identified 15 unequivocal cases, only two of which were of minor salivary gland origin. A case of minor salivary gland clear cell myoepithelial carcinoma of the retromolar region in a 70-year-old man is presented. It is important to recognize the clinicopathologic features of this unusual tumor, because of its histological similarity to several other primary and metastatic clear cell tumors and its aggressive behavior.

Mandibular osteoblastic metastasis of poorly differentiated carcinoma of the thyroid gland

H. Nishikawa, K. Nakashiro, T. Sumida, A. Sugita, H. Hamakawa — 2009-11-27

Abstract: Metastasis of malignant tumors to the oral cavity is rare. The authors report a case of thyroid carcinoma with mandibular osteoblastic metastasis. An 83-year-old female presented with lower jaw swelling and pain. An elastic hard subcutaneous mass was observed in the median mandible. X-ray images confirmed a tumor lesion with periosteal reaction spreading radially from the mandible. A biopsy revealed nests of large, polygonal tumor cells growing in a supporting fibrovascular framework. The patient's anamnesis included thyroid carcinoma with lung metastasis, 2 years ago, treated by total enucleation of the thyroid and excision of the superior lobe of the left lung. Biopsy, primary and metastatic tumor samples all tested positive for thyroglobulin, suggesting a thyroid follicular epithelial origin. Mandibular metastasis of poorly differentiated carcinoma of the thyroid gland was diagnosed. Consent for further treatment was not obtained. The patient died 1 year and 7 months later.

Bilateral temporalis hypertrophy

K. Ali, G. Sittampalam, M.A. Malik — 2009-10-19

Abstract: Temporalis muscle hypertrophy is rare and may present unilaterally or bilaterally. Variable combinations with masseteric hypertrophy are also reported. It may be associated with a parafunctional habit or occur as an idiopathic entity. A host of modalities including CT, MRI, ultrasonography and muscle biopsy may be utilized for diagnosis. While surgical reduction remains an option, medical therapy with boutlinum type A toxin is the treatment of choice. A case of bilateral temporalis hypertrophy in a 38-year-old female is reported.

French

2010-03-01

Maxillary distraction complications in cleft patientsJ. Ferri Rev Stomatol Chir Maxillofacial 2008: 19: 218-223The author presented the applications of maxillary distraction osteogenesis (DO) to children and possible side effects of early surgery on maxillary growth. The author questioned the validity of performing early DO in children. Publications were discussed, particularly about the work of Sarnat (1966) on the growth of the face and jaws after resection of the septal cartilage; Topazian & Korkich-Schapiro (1982) on Lefort I and cranio-facial growth in young animals. The author concluded to warn against early Lefort I with the potential risk of interfering with growth. However, some of the key literature were missing:

Russian

2010-03-01

General principles in treatment of secondary nasal defectsA.G. Jidenko, L.A. Brusova, T.Z. Chkadua, N.A. Sanadunova Klinicheskaya Stomatologyia 2007: 1: 88–90The authors presented their experience based on 30 secondary rhinoplasties over a 3 years period. The patients were followed from 3 months to 3 years post-operatively. The aetiology was trauma in 20 of them and iatrogenic surgery - in 20. 63% of the repair was performed using local tissues for revision, in 13% nasolabial flaps, in 7% septal flaps, in 7% flaps of the neck (trapezius, sternocleidomastoid, intraoral flaps, etc) and in 13% forehead frontal flaps. The surgical results was considered as satisfactory when a functional and aesthetical improvement were obtained and unsatisfactory when complications occurred, such as partial flap necrosis. 2 cases with severe traumas of the face were presented “before and after” pictures, but a detailed analysis of the choices of repair was not presented.

German

2010-03-01

Transoral osteosynthesis of condylar neck fractures using a new three-dimensional osteosynthesis plate designG. Lauer, W. Pradel, M. Schneider, U. Eckelt Mund Kiefer GesichtsChir 2006: 7: 335–340A trans-oral approach for osteosynthesis of the condylar neck fractures can minimize the risk of damaging the facial nerve. However, stable osteosynthesis with two miniplates at the proximal fragment is often not feasible. In order to achieve a stable fixation of condylar neck fractures, a new delta-shaped osteosynthesis plate was developed by the authors and evaluated in this study. A total of 11 patients suffered from 13 condylar neck fractures (Spiessl I: n=2, Spiessl II: n=10, Spiessl III: n=1 and 3 bilateral fractures) were treated through a transoral approach and assessed clinically and radiologically during the follow-up period. Functional parameters and fracture alignment were assessed. Functions returned to normal with a mouth opening of 42mm with protrusion and laterotrusion of more than 5mm 6 months post-operatively. Post-operative radiographic controls showed good fracture alignment in 7 of the 8 patients immediate post-operatively and in 6 of the 8 cases after 6 months. In 12 of the 13 fractures immediate post-operatively and 10 of the 13 fractures 6 months post-operatively, Towne's radiographs showed an anatomical correct position. Neither plate fracture nor bending of the osteosynthesis plates was observed. Loosening of screws was found in 2 patients during plate removal. The authors concluded that the newly developed three-dimensional osteosynthesis plate was easy to handle and offered a sufficiently stable osteosynthesis of condylar neck fractures. Therefore, they recommended that delta-shaped osteosynthesis plate was a good choice for surgical fracture treatment of condylar neck fractures through a transoral approach.

Traumatic neuroma and scar tissue

Jiří Šedý — 2009-11-30

Deng et al. descibed a case of 29-year-old female complaining of numbness in in the region of the left lower lip and chin, based on previous iatrogenic trauma during chin augmentation with alloplastic material based on solid silicone and subsequent development of traumatic neuroma. In their case, the patient did not agree to complete removal of the tumor with the nerve and subsequent nerve transplantation, so only part of the traumatic neuroma was removed for microscopic verification of the tumor character.

Reply to a letter to the editor regarding article “Traumatic neuroma of mental nerve following chin augmentation”

W. Deng, S.-L. Chen — 2009-11-26

We thank the authors for the letter and comments regarding our article. We agree that traumatic neuroma development involves simultaneous nerve repair and defensive mechanisms (i.e. reactive proliferation of perineurial cells) in the region of concomitant wound and scar contraction. We also agree that the treatment strategy was recommended to be targeted towards disruption of the proposed “easily violable balance between nerve regeneration and damage” to obtain a long-term treatment effect.