Craniofacial neurofibromatosis: treatment of the midface deformity

Craniofacial Neurofibromatosis is a benign but devastating disease. While the most common location of facial involvement is the orbito-temporal region, patients often present with significant mid-face deformities. We reviewed our experience with Craniofacial Neurofibromatosis from June 1981 to June 2011 and included patients with midface soft tissue deformities defined as gross alteration of nasal or upper lip symmetry. Data reviewed included the medical records and photobank. Over 30 years, 52 patients presented to and underwent surgical management for Craniofacial Neurofibromatosis at the Chang Gung Craniofacial Center. 23 patients (43%) demonstrated gross mid-facial deformities at initial evaluation. 55% of patients with lip deformities and 28% of patients with nasal deformities demonstrated no direct tumour involvement. The respective deformity was solely due to secondary gravitational effects from neurofibromas of the cheek subunit. Primary tumour infiltration of the nasal and/or labial subunits was treated with excision followed by various methods of reconstruction including lower lateral cartilage repositioning, forehead flaps, free flaps, and/or oral commissure suspension. Soft tissue deformities of the midface are very common in patients with Craniofacial Neurofibromatosis and profoundly affect overall aesthetic outcomes. Distinguishing primary from secondary involvement of the midface assists in surgical decision making.

Transcervical removal of an impacted third molar: an uncommon indication

This article presents a case of and reviews the literature involving the extraoral approach for surgical removal of an ectopic mandibular third molar tooth. Case reports describing extraction of the mandibular third molar using the extraoral approach are very limited. This article describes an unusual case of an impacted, infected, ectopic right mandibular third molar that was positioned at the inferior border and had caused an extraoral draining sinus. Furthermore, the roots were intimately involved with the inferior alveolar nerve (IAN) and had perforated the buccal cortex of the mandible. Surgical removal using a transcervical submandibular approach was deemed necessary to try to preserve the IAN and avoid fracture of the mandible in this 74-year-old patient.

Short-lag spatial coherence imaging of cardiac ultrasound data: initial clinical results

Short-lag spatial coherence (SLSC) imaging is a novel beamforming technique that reduces acoustic clutter in ultrasound images. A clinical study was conducted to investigate clutter reduction and endocardial border detection in cardiac SLSC images. Individual channel echo data were acquired from the left ventricle of 14 volunteers, after informed consent and institutional review board approval. Paired B-mode and SLSC images were created from these data. Contrast, contrast-to-noise, and signal-to-noise ratios were measured in paired images, and these metrics were improved with SLSC imaging in most cases. Three cardiology fellows rated the visibility of endocardial segments in randomly ordered B-mode and SLSC cine loops. SLSC imaging offered 22%-33% improvement (p < 0.05) in endocardial border visibility when B-mode image quality was poor (i.e., 80% or more of the endocardial segments could not be visualized by the three reviewers). The percentage of volunteers with poor-quality images was decreased from 21% to 7% with the SLSC beamformer. Results suggest that SLSC imaging has the potential to improve clinical cardiac assessments that are challenged by clutter.

An autopsy case of tako-tsubo cardiomyopathy presenting ventricular tachycardia after pacemaker implantation

We herein report a rare autopsy case of tako-tsubo cardiomyopathy (TTC) presenting ventricular tachycardia after pacemaker implantation. A 69-year-old male received a dual-chamber pacemaker implantation for complete atrioventricular block. He had no chest symptoms after the operation. Three days later, he developed severe chest pain, followed by syncope. Electrocardiogram showed sustained monomorphic ventricular tachycardia. Despite the use of amiodarone and frequent electrical defibrillation, ventricular tachycardia and ventricular fibrillation were repeated incessantly. He died 24 h after the syncope. The autopsy revealed no hemopericardial effusion, or perforation of leads. There were also no obstructive lesions in the coronary arteries. Myocardial necrosis was observed in the entire circumference and the all layers of the left ventricle. Microscopically, myocardial necrosis was plurifocal and contraction band necrosis. We speculate that catecholamine cardiotoxicity caused ventricular tachycardia in this case. Further studies are needed to clarify the heterogeneity of this disease. .

Clinical and radiographic evaluation of a computer-generated guiding device in bilateral sagittal split osteotomies

The bilateral sagittal split osteotomy (BSSO) is one of the main orthognathic surgery procedures used for managing skeletal mandibular excess, deficiency or asymmetry. It is known to be a technique-sensitive procedure with high reported incidences of inferior alveolar nerve injury, bad splits and post-surgical relapse. With the increasing use of computer-assisted techniques in orthognathic surgery, the accurate transfer of the virtual plan to the operating room is currently a subject of research. This study evaluated the efficacy of computer-generated device at maintaining the planned condylar position and minimizing inferior alveolar nerve injury during BSSO. The device was used in 6 patients who required isolated mandibular surgery for correction of their skeletal deformities. Clinical evaluation showed good recovery of the maximal incisal opening and a reproducible occlusion in 5 of the 6 patients. Radiographic evaluation showed better control of the condyle position in both the vertical and anteroposterior directions than in the mediolateral direction. The degree of accuracy between the planned and achieved screw positions were judged as good to excellent in all cases. Within the limitations of this study and the small sample size, the proposed device design allowed for good transfer of the virtual surgical plan to the operating room.

Maxillofacial injuries due to work-related accidents in the North West of Italy

INTRODUCTION

The aim of this study was to assess the incidence and patterns of work-related maxillofacial injuries, identifying worker categories with a high risk of injury.

MATERIAL AND METHODS

From a systematic computer-assisted database that has continuously recorded patients hospitalized with maxillofacial fractures, only patients with work-related injuries were considered. Occupation, mechanism of injury, and demographic and clinical data were analyzed.

RESULTS

Work-related facial injuries represented the fifth most common cause of injury, with a percentage of 6.3 %. Maxillofacial fractures were most often seen in construction workers (37.9 %). The middle third was involved in 67 % of the cases; the mandible was the most frequently injured site.

CONCLUSIONS

Work-related maxillofacial trauma is rare, but it is often complex and challenging as Facial Injury Severity Scale values show. In agreement with the few published reports, construction workers, together with farm and forestry workers, are at the highest risk of injuries, mainly because of struck by a thrown, projected, or falling object.

Dentition, bone loss, and the aging of the mandible

BACKGROUND

Facial aging is a dynamic process with impact on both the soft tissues and the bones. Despite a growing body of evidence, controversy still exists regarding absolute characteristics of the aging facial skeleton.

OBJECTIVE

The purpose of this study was to investigate various mandibular measurements in different age groups and to delineate the relation of the dentition to these parameters.

METHODS

Ninety Caucasian mandibles were assessed for the following distance landmarks: gonion-gonion, infradentale-gnathion, mental foramen-mandibular crest, mental foramen-inferior mandibular border, gnathion-gonion, condyle-gonion, and gonial angle. The measurements were compared according to age, sex, and dentition.

RESULTS

The number of teeth decreased significantly with increasing age in males (P = .002) and females (P < .001). There were no other statistically significant differences between age groups for the rest of the parameters. The infradentale-gnathion distance (P = .005) and the mental foramen-mandibular crest distance (P < .001) was found to increase with total number of teeth. Other parameters did not show a significant relation to dentition. All parameters were significantly larger in the male subgroups with the exception of gnathion-gonion distance and gonial angle. Bilateral mandibular measurements were symmetric except for the gonial angle, which was more obtuse on the right side in males (P = .007) and females (P = .018).

CONCLUSIONS

Our findings support previous evidence that dentition is the main determinant of the morphology of the mandible. The skeletal characteristics are variable among individuals, and a longitudinal study is required to better understand age-related changes of the mandible.

Length and anatomic routes of the greater palatine canal as observed by cone beam computed tomography

BACKGROUND

Greater palatine canal is used for maxillary nerve block. This procedure has some complications such as proptosis, blindness, and intravascular injection. This study aimed to determine the mean greater palatine canal length (CL) and its typical anatomic routes, as well as provide a reliable facial index for computing the CL by using cone beam computed tomography (CBCT) data.

MATERIALS AND METHODS

A total of 138 CBCT scans (65 females and 73 males) were evaluated. The path of the canal and the CL were determined by sex, age, and side. The mean distance from the inferior border of the infraorbital foramen (IOF) to the crest of alveolar bone between maxillary premolar(CMP) was measured and compared with the CL. Paired t-tests, independent t-test, and one-way analysis of variance (ANOVA) were used for statistical analysis.

RESULTS

The mean of CL was 31.82 ± 1.37 mm (31.70 ± 2.44 mm on the right side and 31.94 ± 2.40 mm on the left side), and the values were 32.49 ± 2.37 mm in males and 30.55 ± 1.76 mm among females (P = 0.001). The mean distance from the IOF to the CMP was 32.01 ± 2.18 mm, which was not significantly different to the CL (P = 0.336).

CONCLUSIONS

The mean CL was significantly different according to sex and side. The mean distance from the IOF to CMP was significantly different according to sex. On comparing the mean distance from the IOF to the CMP with the CL, no significant difference was observed. Therefore, the mean distance from the IOF to CMP may be a reliable clinical index.

Maxillofacial trauma in Tamil Nadu children and adolescents: A retrospective study

Aim:

The aim of this retrospective study is to describe the incidence, aetiology, complexity and surgical indications of maxillofacial injuries in children and adolescents population of Tamil Nadu state of india during period of 4 years.

Materials and Methods:

A retrospective review was conducted among 500 children and adolescents patients of age group 6 years to 16 years suffered or suffering with maxillofacial and skull fractures presenting to ten Level I trauma centers over a 4 year period.The data collected for this study included age, gender, etiology, associated maxillofacial trauma, anatomic site of fracture and treatment.

Results and Conclusion:

In our study the most common cause of trauma was traffic 35%, followed by falls 24% and sports 22%. Mandible was commenest bone prone to fracture, followed by maxilla and nasal bone. Mandible fractures accounted for 72% of all maxillofacial fractures.

Impact of cardiac involvement on the risk of mortality among patients with systemic sclerosis: a 5-year follow-up of a single-center cohort

Cardiac involvement is among the leading causes of mortality in patients with systemic sclerosis (SSc). Previously, we demonstrated in a single-center, cross-sectional study the frequent coexistence of different forms of cardiac involvement in systemic sclerosis including pulmonary arterial hypertension (PAH), coronary artery disease (CAD), and microvascular dysfunction (MVD). The aim of the present study was to investigate the prognostic significance of cardiac involvement. One hundred twenty patients with SSc were enrolled. All cases underwent a non-invasive cardiovascular protocol. In 30 patients with suspected cardiac involvement, right heart catheterization and intra-coronary pressure-wire-supplemented coronary angiography were performed. Clinical follow-up was 5 years. Patients with CAD at the baseline showed a trend for higher cardiovascular mortality while in patients with MVD this difference was significant (26.7 % versus 9.5 %, p = 0.077 and 30 % versus 10.1 %, p < 0.05, respectively). Cardiovascular mortality of PAH cases was higher but, however, did not reach statistical significance 21.4 % versus 10.4 %, p = 0.261. Cardiovascular event-free survival was significantly lower among patients with combinations of two or three disorders (p < 0.05). Multivariate analysis of organ involvements and comorbidities showed that the diffuse cutaneous subset, the presence of kidney involvement, the velocity of the tricuspid regurgitation, as well as diabetes mellitus were independent predictors of overall mortality. MVD and CAD alone or in combination with PAH significantly affected the 5-year cardiovascular mortality. These findings highlight the prognostic importance of coronary disease in patients with SSc [ www.clinicaltrials.gov (Reg. Nr.: NCT00843102)].

Alveolar nerve repositioning with rescue implants for management of previous treatment. A clinical report

The goal of modern implant dentistry is to return patients to oral health in a rapid and predictable fashion, following a diagnostically driven treatment plan. If only a limited number of implants can be placed, or some fail and the prosthetic phase of implant dentistry is chosen to complete the patient's treatment, the final outcome may result in partial patient satisfaction and is commonly referred to as a "compromise." Previous All-on-4 implant treatment for the patient presented here resulted in a compromise, with an inadequate support system for the mandibular prosthesis and a maxillary complete denture with poor esthetics. The patient was unable to function adequately and also was disappointed with the resulting appearance. Correction of the compromised treatment consisted of bilateral inferior alveolar nerve elevation and repositioning without bone removal for lateral transposition, to gain room for rescue implants for a totally implant-supported and stabilized prosthesis. Treatment time to return the patient to satisfactory comfort, function, facial esthetics, and speech was approximately 2 weeks. The definitive mandibular prosthesis was designed for total implant support and stability with patient retrievability. Adequate space between the mandibular bar system and the soft tissue created a high water bridge effect for self-cleansing. Following a short interim mandibular healing period, the maxillary sinuses were bilaterally grafted to compensate for bone inadequacies and deficiencies for future maxillary implant reconstruction.

Surfactant shedding and gas diffusion during pulsed ultrasound through a microbubble contrast agent suspension

Interest in coated microbubbles as agents for therapeutic and quantitative imaging applications in biomedical ultrasound has increased the need for their accurate theoretical characterization. Effects such as gas diffusion, variation in the properties of the coating and the resulting changes in bubble behavior under repeated exposure to ultrasound pulses are, however, still not well understood. In this study, a revised equation for microbubble motion is proposed that includes the effects of gas diffusion, as well as adsorption, desorption and shedding of a surfactant from the bubble surface. This is incorporated into a nonlinear wave propagation model to account for these additional time dependent effects in the response of microbubble populations. The results from the model indicate there can be significant changes in both bubble behavior and the propagated pulse over time. This is in agreement with existing experimental data but is not predicted by existing propagation models. The analysis indicates that changes in bubble dynamics are dominated by surfactant shedding on the timescale of a diagnostic ultrasound pulse and gas diffusion over the timescale of the pulse repetition frequency. The implications of these results for the development of more accurate algorithms for quantitative imaging and for therapeutic applications are discussed.

Morphometric analysis of the maxillary sinus in patients with nasal septum deviation

The aim of this study was to evaluate the relationship between nasal septum deviation, which is common in the general population, and maxillary sinus volume. A retrospective assessment was made for 96 patients with nasal septum deviation without coexisting sinonasal morbidity and compared to 60 healthy individuals. A three-dimensional reconstruction of computed tomography images was used to assess a total of 312 maxillary sinus volumes. Septal deviation angles and volumes were also measured to standardize and determine the severity of the septal deviations. Septal deviations were right-sided in 36.5% of the cases (n = 35) and left-sided in 63.5% (n = 61). Deviation angles varied between 5° and 24.4°, with a mean value of 12.9 ± 5.0. The mean value for the deviation volume was 4.6 ± 1.5 cm(3) (range 1.7-9.4). The right and left maxillary sinus volumes were 11.8 ± 4.7 cm(3) and 11.5 ± 4.4 cm(3), respectively, in control group. Statistically significant discrepancy was observed between the ipsilateral and contralateral maxillary sinus volumes, in regard to the side of the septal deviation in study group. Maxillary sinus volumes were found to be significantly smaller on the ipsilateral side of septal deviation compared with the contralateral side.

Epidermoid cyst localized in the palatine tonsil

Epidermoid and dermoid cysts are benign, developmental lesions that can be encountered anywhere in the body. Our literature search did not result in a finding of any report of an epidermoid cyst located in the palatine tonsils. This is a report of a 42-year-old female patient who underwent a tonsillectomy for diagnostic purposes because of an epidermoid cyst arising from the tonsil which was confirmed by histology.

Endoscopic endonasal approach to the infraorbital nerve with nasolacrimal duct preservation

Objectives Infraorbital nerve (ION) decompression, excision to remove intrinsic tumors, and resection with oncological margins in malignancies with perineural invasion or dissemination are usually accomplished with an open approach. The objective is to describe the surgical anatomy, technique, and indications of the endonasal endoscopic approach (EEA) to the ION with nasolacrimal duct preservation. Design Eleven sides of formalin-fixed specimens were dissected. An anterior maxillary antrostomy was performed. The length of the ION prominence within the sinus and anatomic features of the covering bone were studied. A 45-degree endoscope visualized the infraorbital prominence endonasally. An angled dissector and dural blade allowed for dissection and resection of the ION ipsilaterally and contralaterally. Results The bone features of the ION prominence allowed for ipsilateral dissection in 10 out of 11 sides. In one case with the ION surrounded by thick cortical bone, the dissection could only be started by drilling contralaterally. The 45-degree endoscope visualized 92.2% and 100% of the length of the nerve using the ipsilateral and contralateral nostrils, respectively. Ipsilaterally, 83% of its length was resected, and 96.3% was resected contralaterally. Conclusion The ION can be approached using an ipsilateral EEA with nasolacrimal duct preservation in most cases. The contralateral approach provides a wider angle to access the ION. This technique is primarily indicated in cases where the EEA can be used for tumor resection and oncological margins within the ION.

Time interval after radiotherapy and dental implant failure: systematic review of observational studies and meta-analysis

BACKGROUND

Typically, dental implants are placed in irradiated bone after a delay that exceeds 6 months, but it is not known whether longer delays are beneficial.

PURPOSE

The purpose of the study is to review the literature comparing the failure rate of dental implants placed in irradiated bone between 6 and 12 months and after 12 months from the cessation of radiotherapy.

MATERIALS AND METHODS

Four electronic databases were searched for articles published until February 2013 without language restriction: Lilacs, Medline, Scopus, and the Cochrane Central Register of Controlled Trials. Two reviewers independently assessed the eligibility criteria and extracted data. Fixed effect meta-analysis was performed.

RESULTS

Overall, 3,749 observational studies were identified. After the screening of titles and abstracts, 236 publications were selected, and 10 were included in the final analysis. The pooled relative risk (RR) of failure was RRpooled  = 1.34 (95% confidence interval [CI]: 1.01-1.79), higher in individuals who had dental implants installed between 6 and 12 months after receiving radiotherapy. I(2) indicated nearly 21% heterogeneity (p = .25). Egger's test indicated no evidence of publication bias (p = .62); however, the removal of one study significantly affected the overall RR (RRpooled  = 1.08, 95% CI: 0.77-1.52).

CONCLUSIONS

Placing implants in bone within a period shorter than 12 months after radiotherapy may result in a higher risk of failure; however, additional evidence from clinical trials is needed to verify this risk.

Topography of the mental foramen in human skulls originating from different time periods

The location of the mental foramen is used in a number of maxillofacial surgical procedures and in anthropological examinations. The position of the mental foramen has been reported to vary in different ethnic groups and in different historical populations. The aim of this work was to analyse the topography of the mental foramen in mandibles from selected historical populations from the Pomeranian region in Poland. The material consisted of three groups: 92 skulls from the beginning of the 20th century from Szczecin (earlier name Stettin), and two Mediaeval groups -31 skulls from Rurka (historic Rörchen), 18th-19th centuries, and 50 skulls from Sypniewo (historic Zyppnow), 11th-13th centuries. Distances of the mental foramen in relation to the midline, and to the second corresponding point were measured. Additionally, non-metric traits of the mental foramen were recorded. No significant differences in average diameters of the mental foramina measured on the right and the left sides were observed between historical populations. On both sides, in all groups, the foramen was mainly located between positions of the lower first and lower second premolars. In all three groups the direction of the opening of the mental foramen was superoposterior. The similar level of epigenetic variation was observed in all groups. The position and the direction of the exit were similar to other previously studied European populations.

Possible further reduction in coronary flow velocity reserve in angina pectoris patients after oral glucose loading

BACKGROUND

Previous studies have suggested an increase in myocardial oxygen demand as a cause of postprandial angina. The purpose of this study was to assess coronary flow velocity reserve (CFVR) in the left anterior descending coronary artery (LAD) before and after glucose ingestion in patients with known significant LAD stenosis.

METHODS

Fourteen patients with significant LAD stenosis and 20 subjects without LAD stenosis were enrolled. Transthoracic Doppler echocardiography was performed to measure the average peak diastolic coronary flow velocity (APDV) in the LAD at rest and during adenosine infusion. CFVR was calculated as APDV during adenosine infusion (APDVATP) divided by APDV at rest (APDVrest). APDVrest, APDVATP, and CFVR were assessed during fasting and 30, 60, and 120 min after a 75-g oral glucose loading.

RESULTS

In patients with LAD stenosis, APDVrest at 30 min after glucose loading was the highest at any time point. However, significant differences were not found in the APDVATP among time points in the patients or controls. Consequently, the CFVR in the patients was the lowest at 30 min after glucose loading (fasting, 1.77 ± 0.19; 30 min, 1.48 ± 0.16; 60 min, 1.69 ± 0.17; and 120 min, 1.76 ± 0.19; p < 0.01, ANOVA), as in the controls.

CONCLUSIONS

These findings suggested that the value of CFVR in the LAD was reduced after glucose loading. Myocardial risk area supplied by a stenosed coronary artery may be exposed to myocardial ischemia more frequently during oral glucose loading than during fasting in patients with significant coronary artery stenosis.

Survival and complications of zygomatic implants: a systematic review

PURPOSE

This systematic review attempted to answer the focused questions: "What is the survival rate of zygomatic implants (ZIs)?" and "What are the most common complications related to surgery of zygomatic implants?"

METHODS

An electronic search without date or language restrictions was undertaken in PubMed in March 2012. Titles and abstracts from these results (n = 123) were read for identifying studies that meet the eligibility criteria. Eligibility criteria included studies reporting clinical series of zygomatic implants (ZIs). Because of the scarcity of articles with high-level grades of evidence, all articles, including studies with few case reports, were considered for inclusion. All reference lists of the selected and review studies were hand-searched for additional papers that might meet the eligibility criteria. Simple case report articles were not included. Review articles without original data were excluded. Quantitative data extracted from the included studies that provided data for the period of failure of ZIs were used for the calculation of interval survival rate during each follow-up period and cumulative survival rate (CSR) over a 12-year period.

RESULTS

Thirty-seven studies were identified without repetition and five more studies were included by hand-searching, giving a total of 42; 12 evaluated the use of ZI applied with immediate function protocols and 3 for rehabilitating patients after maxillary resections for tumor ablations. These latter three studies showed smaller ZI success. Postoperative complications reported were as follows: 70 cases of sinusitis, 48 of soft tissue infection, 15 of paresthesia, and 17 cases of oroantral fistulas. However, this number may be underestimated, since most of the studies did not mention the presence or absence of these complications. Most ZI failures were detected at the abutment connection phase (6 months after the surgery of implant placement) or before. The CSR over a 12-year period was 96.7 %.

CONCLUSIONS

Despite the high survival rate observed, there is an impending need for conducting randomized controlled clinical trials to test the efficacy of these implants in comparison with the other techniques to treat the atrophic maxilla. Thus, the findings reported in the review must be interpreted with considerable caution. Moreover, more studies with longer follow-up periods involving adequate number of ZIs are needed. This will help to obtain a better understanding of the survival of ZIs in a long term. It is suggested that multicenter, randomized controlled clinical trials and longer clinical studies should be implemented in this area, before recommending routine use of ZIs for patients could be given. The placement of zygomatic implants requires very experienced surgeons because it is not risk free since delicate anatomic structures such as the orbita and brain may be involved.

Pathological mandibular fractures: a review of the literature of the last two decades

Pathological mandibular fractures are rare, accounting for fewer than 2% of all fractures of the mandible. They could be defined as fractures that occur in regions where bone has been weakened by an underlying pathological process. Pathological fractures usually may follow surgical interventions such as third molar removal or implant placement, result from regions of osteomyelitis, osteoradionecrosis, and bisphosphonate-related osteonecrosis of the jaw, occur because of idiopathic reasons or be facilitated by cystic lesions, benign, malignant, or metastatic tumors. Pathological mandibular fractures may be challenging to treat because of their different etiology and peculiar local and general conditions, often requiring a more rigid fixation. In patients with poor medical conditions, simpler and more limited options may be preferred.

Pérola de esmalte: epidemiologia, morfopatogênese e relevância na clínica odontológica

INTRODUÇÃO: Distúrbios da odontogênese geram anomalias dentárias com relevância diagnóstica e terapêutica. OBJETIVO: O presente artigo teve como objetivos fazer uma revisão sistemática sobre a pérola de esmalte e discutir seu processo formativo, bem como a sua significância na clínica odontológica. MATERIAL E MÉTODO: Três bancos de dados eletrônicos (Pubmed, Cochrane e Biblioteca Virtual em Saúde) foram usados para recuperar artigos científicos dos últimos 30 anos, usando o descritor enamel pearls. RESULTADO: O Brasil ocupa posição de destaque nas publicações temáticas existentes (18%). A etiopatogênese desta anomalia ainda permanece obscura, sendo necessários mais estudos acerca da contribuição de fatores envolvidos com amelogênese ectópica e cementogênese deficiente in situ. Dados epidemiológicos apontam uma frequência variável na população brasileira (0,8 a 8%) e mundial (0,2 a 6,2%), sendo os molares os dentes mais acometidos. Análise morfológica das pérolas de esmalte mostra que esta anomalia de forma e volume pode ser de dois tipos: simples (pérola verdadeira externa ou interna) ou composta (esmalte-dentina ou esmalte-dentina-polpa). É importante o diagnóstico clínico-radiológico diferencial de pérolas de esmalte para permitir o tratamento odontológico adequado, que inclui a ameloplastia como conduta eficaz para minimizar o acúmulo de biofilme oral e a exarcerbação da doença periodontal. CONCLUSÃO: Faz-se necessária a publicação de pesquisas pormenorizadas sobre pérolas de esmalte, a fim de gerar evidências científicas no fazer profissional da Odontologia.

Open versus closed reduction: comminuted mandibular fractures

PURPOSE

The purpose of the study was to review the literature regarding the evolution of current thoughts on management of comminuted mandibular fractures (CMFs).

METHODS

An electronic search in PubMed was undertaken in May 2012. The titles and abstracts from these results were read to identify studies within the selection criteria. Eligibility criteria included studies published in English or German reporting clinical series of CMFs.

RESULTS

The search strategy initially identified 409 studies. Fifteen studies were identified without repetition within the selection criteria. One case report article showing significance in the development of treatment techniques was included. Additional hand-searching yielded five additional papers. Thus, a total of 21 studies were included.

CONCLUSIONS

Open reduction and internal fixation (ORIF) in cases of CMFs are indicated in (a) severe injuries with significant displacement to allow restoration of pretraumatic anatomic relationships, (b) in the edentulous and semi-dentate patient, who may benefit from ORIF of CMFs when stable occlusal relationships are absent, and (c) in cases with multiple fractures of the midface, in which the mandible has to serve as a guide to reposition the midfacial bones. However, there is still a place for closed reduction/conservative treatment (CTR). ORIF in CMFs is not indicated in cases of minimally displaced comminuted fractures that could easily and adequately be treated with CTR. If the surgical team is not well versed in the nuances of rigid internal fixation, or the necessary equipment is not available, it is far better to do simple CTR. However, it would be more reasonable to refer the patient to a hospital that can provide means of ORIF in cases of clear indication of its use in CMFs. In cases where ORIF is indicated, stabilization by compression or any other form of load-sharing osteosynthesis is obviously contraindicated because small fragments cannot be compressed and are not capable of sharing loads. Thus, the ORIF of CMFs is best performed using load-bearing osteosynthesis; most experience has been gained with 2.7-mm reconstruction plates. External pin fixation could be used in cases when there is so much comminution, soft tissue disruption (mostly gunshot wounds), and there are inadequate teeth on either side of the comminuted fracture to control the spatial relationship of the remaining mandibular fragments with maxillomandibular fixation (MMF).

The non-ossifying fibroma: a case report and review of the literature

The non-ossifying fibroma (NOF) is a benign, non-neoplastic lesion most commonly seen in the metaphyses of the long bones in children. While rare, the NOF has been reported in the mandible. The NOF in the extra-gnathic skeleton has a characteristic radiographic appearance, is typically asymptomatic and has a variable histologic make-up. Correlation of the radiographic appearance, clinical presentation and histopathology allows for differentiation of the NOF from odontogenic and non-odontogenic cysts and tumors. We report a new case of this interesting entity and review the radiographic, clinical and histologic features of the gnathic NOF reported in the literature. A thorough search of the English language literature returned a total of 19 cases of NOF involving the gnathic bones.

Maxillary tuberosity fracture and subconjunctival hemorrhage following extraction of maxillary third molar

Extraction of teeth is the most common minor surgical procedure performed. Complication of extraction ranges from periodontal injury to fracture of jaw in the mandible and fracture of tuberosity and oroantral communication in the maxilla. Subconjunctival hemorrhage after extraction of maxillary molar is a very rare complication, and so far, only one case is reported in the literature. We report a case of subconjunctival hemorrhage with maxillary tuberosity fracture after maxillary third molar extraction.

Pathological (late) fractures of the mandibular angle after lower third molar removal: a case series

Introduction

Pathological (late) fracture of the mandibular angle after third molar surgery is very rare (0.005% of third molar removals). There are 94 cases reported in the literature; cases associated with osseous pathologies such as osteomyelitis or any local and systemic diseases that may compromise mandibular bone strength have not been included. We describe three new cases of pathological (late) fracture of the mandibular angle after third molar surgery.

Case presentations

The first patient was a 27-year-old Caucasian man who had undergone surgical removal of a 3.8, mesioangular variety, class II-C third molar 20 days before admission to our clinic. The fracture of his left mandibular angle, complete and composed, occurred during chewing. The second patient was a 32-year-old Caucasian man. He had undergone surgical removal of a 3.8, mesioangular variety, class II-B third molar 22 days before his admission. The fracture, which occurred during mastication, was studied by computed tomography that showed reparative tissue in the fracture site. The third patient was a 36-year-old Caucasian man who had undergone surgical removal of a 3.8, vertical variety, class II-C third molar 25 days before the observation. In this case the fracture of his mandibular angle was oblique (unfavorable), complete and composed. The fracture had occurred during chewing. We studied the fracture by optical projection tomography and computed tomography.

All of the surgical removals of the 3.8 third molars, performed by the patients’ dentists who had more than 10 years of experience, were difficult. We treated the fractures with open surgical reduction, internal fixation by titanium miniplates and intermaxillary elastic fixation removed after 6 weeks.

Conclusions

The literature indicates that the risk of pathological (late) fracture of the mandibular angle after third molar surgery for total inclusions (class II-III, type C) is twice that of partial inclusions due to the necessity of ostectomies more generous than those for partial inclusions. Other important factors are the anatomy of the teeth and the features of the teeth roots. These fractures predominantly occur in patients who are older than 25 years. The highest incidence (67.8% of cases) is found in the second and third week postsurgery. We emphasize that before the third molar surgery it is extremely important to always provide adequate instructions to the patient in order to avoid early masticatory loads and prevent this rare event.

Jael syndrome: removal of a knife blade impacted in the maxillofacial region under local anaesthesia

The presence of retained foreign bodies in the maxillofacial region as a consequence of penetrating injuries from knives is poorly documented in the scientific literature. This manuscript reports the case of a 30-year-old Caucasian with a knife blade lodged in the maxillofacial skeleton. Following clinical and radiographic exams, it was determined that the object had penetrated through the left nostril and nasal septum, in the direction of the right maxillary sinus, and remained impacted without causing injury to important anatomical structures. After systemic assessment and determination of the exact location of the knife blade, the object was removed in an outpatient setting under local anaesthesia. This manuscript aims to report a rare case of a transfacial penetrating injury involving a knife blade that was removed in an outpatient setting while also discussing the proper conduct and treatment options for similar cases in the context of a brief literature review.

Incidence and pattern of maxillofacial fractures in children and adolescents: a 10 years retrospective cohort study

OBJECTIVE

The purpose of this study was to evaluate and compare the demographic characteristics of maxillofacial fractures between children and adolescents.

METHODS

The sample was composed of all children (less than 12 years) and adolescents (between 13 and 18 years old) who presented with maxillofacial fractures during a 10-year period (2000-2009). The age, gender, time of injury, mechanism of trauma, location and pattern of fracture, associated injuries, and treatment methods were recorded and analyzed. Data analysis included Chi-Square test, Fisher exact test. p less than 0.05 was considered significant.

RESULTS

Seventy-nine children (male-to-female ratio, 1.63:1) and 113 adolescents (male-to-female ratio, 3.52:1) sustained 389 maxillofacial fractures. Children were more involved in falls compared to adolescents (44.3% versus 23.9%, p=0.003), while adolescents sustained more assault-related injuries (13.3% versus 2.5%, p=0.010) and motorcycle accidents (22.1% versus 8.9%, p=0.015) compared to children. Children suffered mandibular fractures proportionally higher than adolescents (93.1% versus 64.5%, p<0.001). Adolescents sustained mid-facial fractures more frequently than children (35.5% versus 6.9%, p<0.001). Severe facial fractures occurred more in adolescents compared to children (35.4% versus 14.1%, p=0.001). Open reduction was done more in adolescents than in children (92.3% versus 74.6%, p<0.001).

CONCLUSIONS

The incidence and pattern of maxillofacial fractures in children were remarkably different from that in adolescents. Preventive measures and treatment plan should be designed with differences between the two groups in mind.

Odontoma complexo de grande proporção em ramo mandibular: relato de caso

INTRODUÇÃO: O odontoma é o tumor odontogênico mais comum, sendo considerado também como hamartoma. Sua classificação é baseada na morfologia apresentada, podendo ser classificado como composto, quando apresenta múltiplos dentículos, ou complexo, no caso de uma massa disforme. São geralmente diagnosticados em exames radiográficos de rotina e associados ao atraso no irrompimento dentário. OBJETIVO: Revisar a literatura acerca desse tipo de tumor odontogênico, bem como relatar o caso clínico de um paciente portador de odontoma complexo de grandes proporções envolvendo a região de ramo mandibular.

Enamel pearls in permanent dentition: case report and micro-CT evaluation

OBJECTIVES

To investigate the frequency, position, number and morphology of enamel pearls (EPs) using micro-CT (µCT) and to report a case of an EP mimicking an endodontic-periodontic lesion.

METHODS

Cone beam CT (CBCT) was performed in a patient to evaluate a radio-opaque nodule observed on the left maxillary first molar during the radiographic examination. Additionally, 23 EPs were evaluated regarding frequency, position, number and morphology by means of µCT. The results were statistically compared using the Student's t-test for independent samples.

RESULTS

1 pearl was presented in 13 specimens, while 5 specimens presented 2 pearls. The most frequent location of the EPs was the furcation between the disto-buccal and the palatal roots of the maxillary molars. Overall, the mean major diameter, volume and surface area were 1.98 ± 0.85 mm, 1.76 ± 1.36 mm³ and 11.40 ± 7.59 mm², respectively, with no statistical difference between maxillary second and third molars (p > 0.05). In the case report, CBCT revealed an EP between the disto-buccal and the palatal roots of the maxillary first left molar associated with advanced localized periodontitis. The tooth was referred for extraction.

CONCLUSIONS

EPs, located generally in the furcation area, were observed in 0.74% of the sample. The majority was an enamel-dentin pearl type and no difference was found in maxillary second and third molars regarding diameter, volume and surface area of the pearls. In this report, the EP mimicked an endodontic-periodontic lesion and was a secondary aetiological factor in the periodontal breakdown.

Impaired coronary microvascular function and its association with disease duration and inflammation in patients with psoriasis

SUBJECTS

Thirty-six patients with psoriasis and 56 healthy volunteers were included in this study.

METHODS

Echocardiographic examination included transmitral peak flow velocities of the early phase (E) and late phase (A) of the mitral inflow, left ventricular myocardial velocity measurements, and coronary flow reserve (CFR) measurement.

RESULTS

Baseline coronary diastolic peak flow velocity (DPFV) of left anterior descending artery (LAD) was significantly higher in the psoriasis group. However, hyperemic DPFV was slightly lower and CFR (2.19 ± 0.39 vs. 2.60 ± 0.31, P < 0.0001) was significantly lower in the psoriasis group than in the control group. CFR was significantly and inversely correlated with disease duration, Psoriasis Area and Severity Index (PASI) score, and hsCRP.

CONCLUSION

CFR is decreased in patients with psoriasis, and it correlates to disease duration, PASI score, and inflammation.

Posttreatment CT and MR imaging in head and neck cancer: what the radiologist needs to know

In patients with head and neck cancer, posttreatment imaging can be complicated and difficult to interpret because of the complexity of the surgical procedures performed and the postirradiation changes, but such imaging is critical for the evaluation of (a) the response to therapy and (b) tumor control. Posttreatment changes are affected by the type of surgery performed, reconstruction, neck dissection, and radiation therapy. Three types of flaps are used for reconstruction in the head and neck region: (a) the local flap, with geometric repositioning of adjacent tissue; (b) the pedicle flap, with rotation of donor tissue and preservation of the original vascular system; and (c) the free flap, with transfer of tissue that is revascularized by using microvascular surgical techniques. The posttreatment imaging findings in patients with head and neck cancer can be divided into four groups: altered anatomy secondary to surgical reconstruction, tumor recurrence, potential postsurgical complications, and possible postirradiation changes. Potential postsurgical complications are wound infection, abscess, fistula, flap necrosis, hematoma, chylous fistula, and serous retention. Possible postirradiation changes include mucosal necrosis, osteoradionecrosis, radiation-induced vasculopathy, radiation pneumonitis, radiation lung fibrosis, radiation-induced brain necrosis, and radiation-induced secondary malignancies. A familiarity with the imaging characteristics of posttreatment changes and of the potential complications caused by surgery and irradiation and an ability to differentiate these findings from tumor recurrence are essential for posttreatment surveillance and follow-up management of patients with head and neck cancer.

Anaesthesia of the inferior alveolar and lingual nerves following subcondylar fractures of the mandible

A retrospective chart review of 387 patients with condylar and subcondylar fractures revealed 2 cases of inferior alveolar nerve (IAN) and lingual nerve (LN) anaesthesia following the subcondylar fracture. Only 5 cases have been reported previously. The mechanism of action remains unknown but a review of the literature and an analysis of 120 dry human skulls supported the hypothesis that compression of the mandibular nerve at a high level, close to the foramen ovale, could cause anaesthesia. This complication is rare, because it requires compression at a particular angle. The antero-median angulation of the condyle must be close to the foramen ovale, and the fracture must be a unilaterally displaced fracture. The presence of an enlarged lateral pterygoid plate appeared to enhance the risk of compression. The IAN and LN anaesthesia could be resolved after open reduction of the fracture and IAN and LN anaesthesia constitute a strict indication for an early open fracture reduction.

Zygomatic implants: a critical review of the surgical techniques

PURPOSE

The purpose of the present study is to identify and describe the different surgical techniques for placement of zygomatic implants reported in the literature and discuss the differences between them.

METHODS

An electronic search was undertaken in July 2011. The titles and abstracts from these results (n = 130) were read for identifying studies, which reported different surgical techniques for placement of zygomatic implants, which resulted in 41 articles.

RESULTS

Five different surgical approaches were identified: (1) the classical approach, (2) the sinus slot technique, (3) the exteriorized approach, (4) the minimally invasive approach by the use of custom-made drill guides, and (5) the computer-aided surgical navigation system approach. When the maxilla is severely resorbed, the concavity formed by the ridge crest is small, and the original classical technique should be used. When maxillary resorption generates a large concavity, it would be better to exteriorize the zygomatic implant. The externalized technique has fewer surgical steps than the classical and sinus slot methods, is less invasive, and reduces surgical time. It is recommended that utilization of the sinus slot technique together with the CT-based drilling guide would enhance the final results. Although the technique that uses the computer-aided surgical navigation system approach may produce an improved precision in the clinical procedure, its use is expensive, prolongs the operation time, and is limited to centers that have the necessary equipment for the surgery.

CONCLUSIONS

Preference for one technique over the other should take into consideration the concavity formed by the ridge crest, maxillary sinus, and region of implant insertion in the zygomatic bone.