Optimal Timing of Secondary Alveolar Bone Grafting: A Literature Review

PURPOSE

Secondary alveolar bone grafting (SABG) during mixed dentition is the standard of care for alveolar clefts. However, early SABG at 4 to 7 years of age before the eruption of lateral incisors versus late SABG at 8 to 12 years of age before the eruption of maxillary permanent canines is still debated. The purpose of this study was to perform a systematic review of the literature to evaluate the outcomes of early SABG in residual bone volume or degree of bone resorption, maxillary canine movement or impaction rate, complications, and esthetic outcomes and to compare outcomes of early versus late SABG.

MATERIALS AND METHODS

A comprehensive search of the PubMed database was performed according to PRISMA guidelines. Keywords for alveolar cleft repair and inclusion criteria were used to screen articles for final review.

RESULTS

The initial search yielded 6,278 articles, of which 4 retrospective and 4 prospective studies were chosen for final review. Of these, 7 studies compared outcome variables between early and late SABG and 1 looked at bone formation of patients who underwent only early SABG. For outcome variables, 3 studies assessed bone volume with radiographic evaluation, 2 estimated maxillary permanent canine impaction rate, 1 evaluated surgical complications, operative time, and length of hospital stay, and 1 looked at anterior incisor crown length. Overall, 6 studies concluded that early SABG provides a better outcome than late SABG and 2 found comparable results across the aforementioned variables.

CONCLUSIONS

This review suggests that the existing data support the concept of early SABG; however, the data are not sufficient for a definitive conclusion. A well-planned prospective study is needed to further investigate the rationale for early SABG.

A Single Lab Test to Aid Pierre Robin Sequence Severity Diagnosis

Objective:

The workup of patients with Pierre Robin sequence (PRS) consists of a physical examination, O2 saturation, and polysomnography to determine the severity of respiratory obstruction and need for surgery. We suggest that capillary blood gas (CBG) may be a better physiologic representation of airway obstruction and should be routinely used in the management of patients with PRS.

Design:

This is a multicenter study based on a retrospective review of medical records.

Setting:

The study was performed at tertiary care centers.

Interventions:

Patients with PRS <1 year old underwent mandibular distraction osteogenesis.

Main Outcome Measure:

Using successful treatment outcome as a reference standard, receiver operating characteristic (ROC) curve was used to determine the accuracy of the diagnostic test and values for the best sensitivity and specificity to determine the need for surgical intervention.

Results:

Of 73 patients, 48 had sporadic PRS, 23 had syndromes, 2 had micrognathia, not otherwise specified. Mandibular distraction osteogenesis was performed in 62 patients at a mean age of 39 days. The mean initial Apnea-Hypopnea Index (AHI) in nonsurgical versus surgical groups was 10 versus 31 ( P = .063), pH 7.41 versus 7.34 ( P = .003), pCO2 43 versus 56 ( P < .001), and HCO3 27 versus 30 ( P = .022). The ROC curve showed that pCO2 of 49.5 has the best specificity (100%) and sensitivity (72.6%) profile in terms of need for definitive airway.

Conclusion:

A simple CBG heel stick may better predict the physiologic effects of obstructive apnea; therefore, it should be added to the algorithm of PRS workup.

Impact of the Distance of Maxillary Advancement on Horizontal Relapse After Orthognathic Surgery

Background:

The maxillary horizontal relapse following Le Fort I advancement has been estimated to be 10% to 50%. This retrospective review examines the direct association between the amounts of maxillary advancement and relapse. We hypothesize that the greater the advancement, the greater the relapse amount.

Method:

Patients with class III skeletal malocclusion underwent maxillary advancement with either a Le Fort I or a Le Fort I with simultaneous mandibular setback (bimaxillary surgery) from 2008 to 2015. Patients were assessed for a history of cleft lip or cleft palate. Patients with known syndromes were excluded. Cephalometric analysis was performed to compare surgical and postsurgical changes.

Results:

Of 136 patients, 47.1% were males and 61.8% had a history of cleft. The mean surgery age was 18.9 (13.8-23) years and 53.7% underwent a bimaxillary procedure. A representative subgroup of 35 patients had preoperative, immediate postoperative, and an average of 1-year postoperative lateral cephalograms taken. The mean maxillary advancement was 6.3 mm and the horizontal relapse was 1.8 mm, indicating a 28.6% relapse. A history of cleft and amount of maxillary advancement were directly correlated, whereas bone grafting of the maxillary osteotomy sites was inversely correlated with the amount of relapse ( P < .05).

Conclusions:

Our data suggest positive correlation between amount of maxillary advancement and horizontal relapse as well as a positive correlation between history of cleft and horizontal relapse. Bone grafting of the maxillary osteotomy sites has a protective effect on the relapse.

Updates on the Management of Non-Melanoma Skin Cancer (NMSC)

Non-melanoma skin cancers (NMSCs) are the most common malignancy worldwide, of which 99% are basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) of skin. NMSCs are generally considered a curable diseases, yet they currently pose an increasing global healthcare problem due to rising incidence. This has led to a shift in emphasis on prevention of NMSCs with development of various skin cancer prevention programs worldwide. This article aims to summarize the most recent changes and advances made in NMSC management with a focus on prevention, screening, diagnosis, and staging.

Detection of craniospinal dissemination of intracranial germ cell tumours based on serum and cerebrospinal fluid levels of tumour markers

Nineteen intracranial germ cell tumours treated during the past 11 years were evaluated retrospectively. The tumours were classified into three groups according to the level of alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (HCG) in serum and cerebrospinal fluid, and the optimal treatment for each group was determined. Group A consisted of patients with normal titres of AFP and HCG, group B of patients with relatively high titres (< 10 times normal), and group C comprised patients with higher titres ( 10 times normal levels). In group A, an appropriate field and dose of irradiation was necessary to prevent craniospinal dissemination. In group B, none of four patients who underwent total or subtotal resection of the tumour had craniospinal disseminatio n or tumour recurrence, whereas dissemination occurred in four further patients, including two who had received radiochemotherapy only, and two who had undergone partial resection of the tumour. While patients in group C had dissemination at the time of initial diagnosis, most patients in group B developed dissemination more than 10 months after initial treatment, suggesting that the type of treatment received as first line therapy is important in patients in this group. The prognosis of patients in group C, however, was unaffected by the priority given to either surgery, radiation or chemotherapy as first line treatment. Craniospinal dissemination can be prevented in patients with germ cell tumours who have a relative increase in levels of AFP and HCG by aggressive removal of the tumours as first line therapy, regardless of the type of adjuvant therapy given.

Effects of acute percutaneous transluminal recanalization on cerebral embolism

The effects of percutaneous transluminal recanalization (PTR) on critical hemodynamics of cerebral embolism were studied using stable xenon-enhanced computed tomography in patients within 6 hours after onset. PTR was conducted in 10 cases (PTR group) and not conducted 8 cases (non-PTR group). The development of infarction was followed by CT scan. In the cortical arterial regions, the lowest cerebral blood flow (CBF) value in regions of interests (ROIs) without development of infarction was 12.9 ml/100 g/min in the PTR group and 17.0 ml/100 g/min in the non-PTR group. In ROIs with a cerebrovascular reserve capacity (CRC) less than 0 ml/100 g/min, even with a CBF greater than 12.9 ml/100 g/min, 3 of 4 ROIs underwent cerebral infarction. PTR conducted within 6 hours after onset of cerebral embolism would prevent the cortical regions with a CBF greater than 12.9 ml/100 g/min and with a CRC greater than 0 ml/100 g/min from undergoing cerebral infarction.

A case of large neonatal arteriovenous malformation with heart failure. Color Doppler sonography, MRI and MR angiography as early non-invasive diagnostic procedures

We report a case of a large arteriovenous malformation (AVM) of neonatal onset with heart failure. Transfontanel color Doppler sonography revealed abnormal vessels in the early stage of the investigation. Magnetic resonance imaging (MRI) revealed numerous flow voids suggesting abnormal vessels, and magnetic resonance angiography (MRA) disclosed numerous bizarre abnormal vessels. Color Doppler sonography is a convenient and appropriate procedure for the early bedside diagnosis of neonatal AVMs. MRI and MRA can replace cerebral angiography for the diagnosis of neonatal AVMs.

Brain metastasis of testicular tumor with massive hemorrhage--report of two cases

The authors report two cases of brain metastasis from testicular tumor with massive, sudden intratumoral hemorrhage. In both cases, the hemorrhage occurred during the 1st admission day and carried a high risk of fatality. Early, aggressive surgical removal is advisable before general deterioration. Postoperative chemotherapy with an agent different from the one applied to primary lesion is also recommended because of drug tolerance.

[One pedigree of "moyamoya" disease]

One familial case of "moyamoya" disease affecting three patients is reported. The patient in Case 1 was a 28-year-old female. She had suffered from motor weakness of the right limbs in her infantile period. She visited our hospital because of sudden headache and left motor weakness associated with nausea and vomiting. On admission, CT scan revealed cerebral hemorrhage in the right caudate nucleus with intraventricular clots and infarction in the left parietal lobe. Angiography showed stenosis of the left ICA terminal portion and occlusion of the right side, with moyamoya vessels in the basal area. The patient in Case 2 was a 54-year-old female, who was the mother of Case 1. After an operation for acute upper intestinal bleeding, she suffered from cerebral infarction. CT scan revealed large low density areas in the territory of the bilateral MCA. Angiography showed stenosis of the bilateral ICA terminal portions, occlusion of the right MCA, stenosis of the left MCA, and moyamoya vessels in the basal area. The patient in Case 3 was a 40-year-old female, who was a younger sister of Case 2. She had a convulsive attack in her infantile period. She visited our hospital because of gradually worsening headache. CT scan revealed multiple infarctions in the left paraventricle, the right parieto-occipital and occipital lobe. Angiography showed occlusion of the bilateral ICA terminals with moyamoya vessels in the basal and the ethmoidal areas. The patient in Case 2 died immediately. Surgery for reconstruction of hemodynamics was performed in Case 1 and 3.(ABSTRACT TRUNCATED AT 250 WORDS)

[Analysis of recurrences of meningiomas following neurosurgical resection]

A clinical and pathological study of 124 surgically treated patients with intracranial meningiomas was carried out to evaluate factors influencing recurrence. The patients ranged in age from 8 years to 75 years. Thirty-five (28.2%) were males and 89 (71.8%) were females. Recurrences occurred in 18 patients, once in eleven, twice in six, four times in one. The period from first surgery to recurrence ranged from 5 months to 84 months (mean 29.9 months). Age, sex, site of tumor, surgical grading, and histology were selected as analytic factors. Simpson's classification was used as surgical grading. All the patients with recurrences were younger than 60 years old, and particularly in the patients who were younger than 40 years the recurrence rate was high. Mean age of the group with recurrence was 41.8 years, which was significantly younger than that of the group without recurrence (52.0 years). In the group with recurrence, ten were males and eight were females. The recurrence rate was 28.6% in males, and was 9.0% in females. Thus the recurrence rate was significantly higher for males than for females (p = 0.016). It also seemed that the period from first surgery to recurrence was earlier for males than for females. The patients with meningiomas at posterior fossa or sphenoid ridge often had recurrences, and the recurrence rate was 29.4% and 21.7%, respectively. But these recurrence rates were not significantly higher than those at other sites. On the contrary, no recurrences occurred at convexity, intraventricle, and olfactory groove.(ABSTRACT TRUNCATED AT 250 WORDS)

Interposition of a saphenous vein graft for early recurrent carotid stenosis--report of two cases

The main cause of recurrent stenosis within 24 months of carotid endarterectomy is myointimal hyperplasia. In these cases, reoperation is technically difficult because there is no true plane of dissection between the recurrent plaque and the remaining vessel wall. The authors present two cases of early recurrent stenosis after carotid endarterectomy, both of which were successfully treated by an interposed saphenous vein graft. In the first case, angiography suggested that the recurrent stenosis was due to atherosclerosis. In the second case, however, myointimal hyperplasia was suspected to be the cause, and this was confirmed by histological examination of the surgical specimen. The authors' experience indicates that anastomosis with an interposed saphenous vein graft is a reliably effective treatment for early recurrent carotid stenosis.

[Intracranial neurinomas of the jugular foramen and hypoglossal canal]

Intracranial neurinomas of the jugular foramen and the hypoglossal canal are relatively rare. Most reports have been of either single cases or of only two or three patients, and few large series exist in the literature. Although some of these tumors present palsies of the ninth, tenth, and eleventh cranial nerves as a jugular foramen syndrome, this is not always present. Unexpectedly, symptoms involving the eighth nerve are more frequently than those of ninth, tenth and eleventh nerves. This variability of clinical symptoms frequently leads to an initial misdiagnosis of glomus jugulare, acoustic or hypoglossal neurinoma. We report 2 cases of jugular foramen neurinomas and 2 cases of hypoglossal neurinomas. Our review of literature has tabulated 92 jugular foramen neurinomas and 34 hypoglossal neurinomas. These neurinomas had become considerably large in size by the time they were detected. So, we should endeavor, by clinical or neuroradiological finding to detect them at the early stage when they exert less influence on the brain. In this series we discuss clinical pictures of these neurinomas.

Roentgenological investigation of cavernous sinus structure with special reference to paracavernous cranial nerves

We have evaluated the anatomical structure of cavernous sinuses in parasellar blocks obtained from adult cadavers to gain clinically useful information. Ten microdissectional studies of parasellar blocks (20 sides of cavernous sinus) were carried out with special emphasis on the course of paracavernous cranial nerves (3rd to 6th). These were also examined on plain radiographs. Secondly, CT investigations of the cavernous sinuses (notably as to paracavernous cranial nerves) were undertaken in twenty clinical cases having presumed parasellar lesions and in three parasellar blocks from cadavers. The results from microdissectional studies and plain radiographs were as follows. It was found that the 3rd cranial nerve entered the lateral wall of the cavernous sinus close to the antero-inferior part of the posterior clinoid on lateral projection. The 4th cranial nerve, on the other hand, entered near the postero-inferior portion of the posterior clinoid on the same view. Variations in Parkinson's triangle were fairly often noted, although marked asymmetry was not seen in individual cases. From CT findings, it was found that a postenhanced, magnified direct coronal study was essential for identifying paracavernous cranial nerves more clearly. The 3rd and 5th cranial nerves were fairly well identified on axial and coronal projections. Careful radiological investigation including plain skull radiographs & CT seems to be of value for those who diagnose or treat parasellar lesions.

[Two cases of cerebral aneurysms combined with polycystic kidneys]

Two cases of cerebral aneurysm combined with polycystic kidneys (PCKs) were presented. Case 1, a 24-year-old hypertensive male, was referred to our clinic owing to sudden onset of severe headache at August 20, 1982. Neurological findings on admission were stuporous, right vitreous hemorrhage (so-called Terson's syndrome), and hypertension. CT scans showed subarachnoid hemorrhage, and right MCA bifurcation aneurysm with marked vasospasms by cerebral angiography was revealed. Intentional delayed operation with V-P shunt was performed. He discharged with mild left upper limb paresis, and visual impairment on the right. Bilateral PCKs were confirmed by postoperative DIP and CT scan. Case 2, a 51-year-old female, who suddenly complained of severe headache, was referred to our department 3 days after subarachnoid hemorrhage. One year previously, she had been pointed out PCKs. Neurological findings on admission at February 29, 1980, were drowsy, left third cranial nerve palsy, and hypertension. Cerebral angiography showed multiple aneurysms (bilateral IC-PC & A-com). Neck clipping (1-IC-PC & A-com) and coating (r-IC-PC) were performed at the next day of admission, and V-P shunt operation was followed about 8 weeks after first operation. About 2 weeks after discharge, she suddenly became loss of consciousness and expired. Autopsy revealed intracerebral hemorrhage in left basal ganglia and thalamus. Both kidneys were PCKs of Potter type 3 and cysts of the liver were also noted. In young hypertensive patients with cerebral aneurysms, it should be in mind whether PCKs may be combined or not, and cerebral angiography in PCKs were reasonable to find out harbored cerebral aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)