Precise Coronoidectomy and Zygomatic Arch Reduction for Unilateral Hyperplasia of the Coronoid Process (Jacob's Disease) via Computer-aided Design and Manufacture

Jacob disease is the new formation of a pseudo-joint between both of enlarged coronoid process and even zygomatic arch. A 23-year-old female patient with facial asymmetry and limited mouth opening was reported. Computed tomography images showed the classic symptom of Jacob disease with a mushroom-shaped tumor mass from the coronoid process a pseudoarthrosis joint with zygomatic arch. Coronoidectomy and zygomatic arch reduction were planned to operate based on computer-aided design/computer-aided manufacturing. During the actual operation, the excision of coronoid process and reconstruction of zygomatic arch were all navigated by 3-dimensional-printed surgical templates as designed through an intraoral approach. As a result, the enlarged coronoid process was smoothly removed without sequela and mouth opening along with facial symmetry were successfully improved. The authors suggested that computer-aided design/computer-aided manufacturing should be considered as an auxiliary technique to shorten operation time and enhance surgical accuracy.

Minimally Invasive Approaches to the Lateral Cavernous Sinus and Meckel's Cave: Comparison of Transorbital and Subtemporal Endoscopic Techniques

BACKGROUND

Transorbital and subtemporal keyhole approaches have recently been proposed to approach lesions in the lateral wall of the cavernous sinus (CS) and Meckel's cave (MC). Our goal was to compare these approaches and suggest indications for each of them.

METHODS

Five cadaver heads (10 sides, 40 procedures) were used. The lateral transorbital approaches were carried out without and with the removal of the lateral orbital rim, herein referred to as the lateral transorbital approach (LTOA) and the lateral orbital wall approach (LOWA). The subtemporal approaches were performed without and with the removal of the zygomatic arch, referred to as the subtemporal approach (STA) and the subtemporozygomatic approach (STZA). Five targets were chosen and 2 triangles were created representing the lateral wall of the CS and MC. Stereotactic measurements were quantified to calculate angles of attack, surgical freedom, and temporal lobe retraction for each approach.

RESULTS

LTOA presented the smaller horizontal angles of attack. LOWA increased the angles to the same level of STA and STZA. STA and STZA presented larger vertical angles of attack. The surgical freedom presented gradual increase from LTOA to LOWA, STA, and STZA. STA and STZA needed greater temporal lobe retraction for most targets.

CONCLUSIONS

LTOA is a good option to biopsy a lesion in the lateral wall of the CS and LOWA increased the surgical corridor to work with microsurgical techniques. STA and STZA could be better options when wide exposure is necessary, but temporal lobe retraction should be taken into consideration.

Zygomatic bone metastasis from hepatocellular carcinoma and the therapeutic efficacy of apatinib: A case report and literature review

RATIONALE

Hepatocellular carcinoma (HCC) metastases to the zygomatic bone are extremely uncommon, and the treatment of target drugs against such case is unknown.

PATIENT CONCERNS

A 48-year-old male patient was admitted to our hospital under suspicion of an advanced liver tumor due to an increase in levels of alpha-fetoprotein (AFP) after radiofrequency ablation for independent nodule in his liver 1 month before. He had a hepatitis B virus (HBV) history for 20 years without treatment.

DIAGNOSIS AND INTERVENTIONS

A diagnosis of primary HCC was made based on pathological examination following right hepatectomy. Seven months after the surgery, a mass in S8 was identified and treated by ARF. Twenty days later, a right zygomatic mass was observed and the incisional biopsy revealed metastasis from HCC. Due to side effects of chemotherapy, the metastatic zygomatic mass was treated with radioactive seed implantation. Despite these interventions, there was steady increase in AFP values as well as increase in size of the zygomatic mass. Hence, the patient was started on apatinib with a dose of 500 mg/day from 1 to 28 days per cycle for a duration of 10 months.

OUTCOMES

The AFP values were significantly decreased but the size of the zygomatic mass continued to increase indicating progression of disease. But the progression-free survival was more than 10 months. The patient exhibited adverse reactions which were controllable by symptomatic treatments. As of last follow-up, the patient is unwell with pain in the face, blurred vision in the right eye, dyscrasia, and exhibited difficulty in opening his mouth.

LESSONS

HCC metastases to the zygomatic bone are very aggressive with a very low incidence and immunohistochemistry is useful diagnostic indicators. Still now, there is no optimal treatment strategy for these patients. Apatinib may be a promising drug in the treatment of HCC metastases to the zygomatic bone.

Bone Resection Versus Setback in Reduction Malarplasty: A Quantitative Analysis of the Migration of the Summit of the Zygoma

BACKGROUND

We hypothesized that the amount of bone resection and setback together controls the effect of reducing the zygomatic body during reduction malarplasty; however, quantitative analyses of this movement are lacking.

METHODS

A retrospective study of patients who underwent reduction malarplasty between Aug. 2013 and Jan. 2015 was performed. We used 3-dimensional computed tomography (3D CT) scanning to measure movements of the summit of the zygoma (SOZ). We analyzed 394 zygomas in 197 patients.

RESULTS

The bone resection amount was not significantly correlated with the anteroposterior movement of the SOZ (p = 0.270); in contrast, the setback amount, was significantly correlated with anteroposterior SOZ movement (p < 0.001). The bone resection amount was not correlated with cephalocaudal movement (p = 0.158); however, cephalocaudal movement was significantly correlated with the setback amount (p < 0.001). Both the bone resection amount and the setback amount were correlated with mediolateral movement (p < 0.001). The amount of bone resection determined the mediolateral movement. Both the bone resection amount and the setback amount were correlated with the mean movement distance of the SOZ (p < 0.001). Both the R (2) (0.704 > 0.084) and β (0.839 > 0.290) values indicated that the setback amount made a larger contribution to the SOZ movement distance than did the bone resection amount.

CONCLUSIONS

Whereas bone resection was the major factor in the medial movement of the SOZ, bone setback was the major factor in the anterior and superior movement of the SOZ and a minor factor in the medial movement. The results indicate that both bone reposition and bone resection are important factors in maximizing surgical results of the reduction malarplasty.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The effects of denervation and formoterol administration on facial growth

OBJECTIVE

To identify and demonstrate possible alterations of skeletal structures which might follow either unilateral surgical denervation of the masseter muscle, unilateral intramuscular injection of formoterol directly into the masseter muscle, or intramuscular formoterol injection after surgical denervation.

MATERIALS AND METHODS

Male Sprague Dawley rats (N = 16; four weeks of age) were prepared as four groups: 1. surgical sham + saline injection into the masseter muscle (sham); 2. surgical denervation of the masseter muscle only (den.); 3. surgical denervation of the masseter muscle plus intramuscular formoterol injection into the affected muscle (den.+form.); 4. intramuscular formoterol injection into the masseter muscle only (form.). The specimens were submitted for CT examination, the skulls and hemimandibles were photographed and measurements of craniofacial bones were made.

RESULTS

In this relatively small sample, comparisons between non-experimental and experimental sides revealed differences, both within the groups and for the same measurements between groups, with the den. and den.+form. groups showing the most change. Relative increases in the gonial angle shown in these groups occurred bilaterally, with the change on the experimental side always greater in magnitude than the change on the contralateral side.

CONCLUSIONS

Surgical denervation of the masseter muscle leads to an alteration in the size and shape of the skeletal structures close to the zygoma and the mandible. The intramuscular injection of formoterol into denervated masseter muscle seems to limit this skeletal alteration after surgical denervation.

Biomechanical evaluation of sagittal maxillary internal distraction osteogenesis in unilateral cleft lip and palate patient and noncleft patients: a three-dimensional finite element analysis

OBJECTIVE

To compare the pattern and amount of stress and displacement during maxillary sagittal distraction osteogenesis (DO) between a patient with unilateral cleft lip and palate (UCLP) and a noncleft patient.

MATERIALS AND METHODS

Three-dimensional finite element models for both skulls were constructed. Displacements of the surface landmarks and stress distributions in the circummaxillary sutures were analyzed after an anterior displacement of 6 mm was loaded to the elements where the inferior plates of the distractor were assumed to be fixed and were below the Le Fort I osteotomy line.

RESULTS

In sagittal plane, more forward movement was found on the noncleft side in the UCLP model (-6.401 mm on cleft side and -6.651 mm on noncleft side for the central incisor region). However, similar amounts of forward movement were seen in the control model. In the vertical plane, a clockwise rotation occurred in the UCLP model, whereas a counterclockwise rotation was seen in the control model. The mathematical UCLP model also showed higher stress values on the sutura nasomaxillaris, frontonasalis, and zygomatiomaxillaris on the cleft side than on the normal side.

CONCLUSIONS

Not only did the sagittal distraction forces produce advancement forces at the intermaxillary sutures, but more stress was also present on the sutura nasomaxillaris, sutura frontonasalis, and sutura zygomaticomaxillaris on the cleft side than on the noncleft side.

Desmoplastic fibroma: report of rare lesion in unusual craniofacial location

Desmoplastic fibroma (DF) is a benign but aggressive intraosseous tumor. These lesions are categorized as central tumors of bone. They are composed of small fibroblasts in a setting of abundant extracellular material, which is rich in collagen. DF represents fewer than 0.1% of all bony tumors. They can be found in any part of the skeleton. Based upon on our literature review, we believe this is the second reported case of desmoplastic fibroma occurring in the zygoma area.

The buccal fat pad flap: an option to prevent and treat complications regarding complex zygomatic implant surgery. Preliminary report

PURPOSE

To evaluate the use of the buccal fat pad flap (BFPF) technique as an option to prevent complications in the treatment of patients with atrophic maxillae rehabilitated after complex zygomatic implant surgery.

MATERIALS AND METHODS

A retrospective study was made of completely edentulous patients submitted to zygomatic implant surgery between May 2005 and November 2007. Patients with severely atrophic maxillae received conventional and zygomatic implants and were followed after the implants were loaded. Preoperative evaluation included panoramic radiography and computed tomographic scans of the maxilla to identify the anatomic conditions and presence of pathology.

RESULTS

Eight male patients with a mean age of 57 years and atrophic maxillae were rehabilitated with zygomatic implants placed using the BFPF technique. The BFPF technique was used in complex situations, including oroantral communication-associated sites, areas that had lost the sinus wall, and extrasinus implant placement. A total of 16 conventional implants, 4 long (21-mm) tilted implants, and 22 zygomatic implants was placed. The patients were rehabilitated with fixed prostheses and were followed for a minimum of 15 months. None of the conventional implants failed and none of the zygomatic implants failed or presented with soft tissue complications.

CONCLUSION

The BFPF presented a high success rate, demonstrating that it is a viable and predictable treatment option to prevent and treat soft tissue complications in complex zygomatic implant surgery.

Coronomaxillary space and its significance in complete denture retention--case reports

The coronomaxillary space defines the distal-most extension of the maxillary denture border, and it usually is tightened during mouth opening. It has been reported that its adequate filling or overfilling is helpful in prosthesis retention. Two types of individual anatomical variations can affect the size of this space: vertical or lateral. With vertical variations, the space increases or does not vary when the mouth is opened; therefore, the prosthesis border must be thicker to obtain adequate retention. With lateral variations, the coronomaxillary space is reduced when the mouth is opened; therefore, the prosthesis border must be thin. The case reports presented here show how complete denture retention can be augmented by the careful recording of the coronomaxillary space dimensions.

Development of an osteosarcoma following dental extraction after allogeneic stem cell transplantation

OBJECTIVES

Radio-induced sarcoma is known to occur several years following bone irradiation especially when this treatment is combined to high dose chemotherapy regimens prior to allogeneic haematopoietic stem cell transplantation (HSCT) in very young children. However, little is known about the stimulus of aggressive bony surgery in the development of these tumours.

MATERIAL AND METHODS

We report the case of a young girl in whom dental extraction was rapidly followed by the occurrence of a localized tumour 11 years after allogeneic haematopoietic stem cell transplantation using total body irradiation (TBI) for a haemophagocytic lymphophistiocytosis (HLH).

RESULTS

This tumour involved tooth socket and all the right side of the mandible and was diagnosed as an osteogenic osteosarcoma of the zygomatic bone.

CONCLUSION

This tumour had the characteristics of a radio-induced sarcoma. Thanks to the very short time between the dental extraction and the occurrence of the osteosarcoma at the same location, we discuss the role of the dental extraction as a trigger of osteosarcoma development.

Imaging and histopathological features of Jacob's disease: a case study

A pathologically elongated coronoid process forming a joint with the zygomatic arch and bone is termed as "Jacob's disease." Herein, we present a case of Jacob's disease, which has rarely been reported in the literature. Moreover, very few cases have been reported from the Indian subcontinent. A 28 years-old male reported to us with progressive restriction of mouth opening. After detailed imaging, coronoidectomy was performed through an intraoral approach. A mushroom-shaped gross specimen was obtained. Osteochondroma of the coronoid process was diagnosed based on the histopathologic examination of the excised tissue. Although Jacob's disease is seldom considered in the list of differential diagnoses for restricted mouth opening, our case highlights the need for evaluation of the coronoid process, which is usually ignored during routine radiographic examination. The report also highlights the miniscule incidence of this condition in the available literature.

Surgical management of primary chronic osteomyelitis of the jaws in children: a prospective analysis of five cases and review of the literature

INTRODUCTION

Primary chronic osteomyelitis (PCO) of the jaws is an uncommon non-suppurative inflammatory disease of unknown origin. Although the disease is not age-specific, only sparse cases with onset during childhood or adolescence have been reported in the literature.

PURPOSE

This study seeks to present five cases of maxillofacial PCO in children and to evaluate the effectiveness of the applied therapeutic protocol. A review of the literature concerning diagnosis and treatment of PCO with special emphasis on surgical therapy is also performed.

PATIENTS AND METHODS

Demographic data, clinical, radiographic and histopathologic findings, blood tests results, and the treatment protocol applied to five young patients suffering from PCO and referred to the Department of Oral and Maxillofacial Surgery at "A. & P. Kyriakou Children's Hospital" over the past 5 years are presented. Decortication and contouring of the affected bone were performed; antibiotics were administered for a short period of time and the patients remained under follow-up evaluation.

RESULTS

The posterior mandible was affected in four cases and the maxilla-zygomatic bone in one case. All patients showed remission of signs and symptoms after surgical treatment. The postsurgical clinical course was uneventful in all cases. However, recurrences have been noted, as reported in the literature.

CONCLUSION

PCO of the jaws is a complex clinical entity, presenting both a diagnostic and therapeutic challenge, especially in young patients. Surgical treatment in conjunction with antibiotics and non-steroid anti-inflammatory drugs proved to be beneficial and to improve considerably the patients' quality of life. Nevertheless, exacerbation of the disease may appear and regular follow-up of the patients is required.

Assessment of the posteroanterior cephalograms of the parents of children with cleft lip and/or cleft palate in Latvia

OBJECTIVE

To compare the craniofacial morphology of parents of children with cleft lip with or without palate (CL±P), children with isolate cleft palate (CP) and individuals without family history of orofacial clefting in Latvia.

MATERIALS AND METHODS

Posteroanterior (PA) cephalograms were obtained from all participants: 37 couples of noncleft biological parents of children with nonsyndromic CL±P and 17 couples of noncleft biological parents of children with nonsyndromic CP (the parents groups were made dividing the parents after gender and children cleft type). The control groups consisted of 40 females and 42 males, who had no history of clefts in the family. A conventional cephalometric analysis was used to measure various measurements of facial widths.

RESULTS

Statistically significant differences (decreased facial and biorbital width) were found between fathers of children with CP and males from the control group. Results showed asymmetry of zygomatic width (left side dominance) in all parents groups compared with the control groups. The asymmetry was detected in maxillary part (left side dominance) in CP children mothers and females and males control groups.

CONCLUSION

Some statistical significant differences in the PA cephalometric measurements among parents groups of children with CL±P and CP, and control groups were found. However the differences among study groups and the control groups were small, often not larger than variations in the population.

Percutaneous approach to the foramen ovale: an anatomical study of the extracranial trajectory with the incorrect trajectories to be avoided

OBJECTIVE

Meckel's Cave may be accessed percutaneously through the foramen ovale (FO). Detailed knowledge of the region's anatomical surroundings is invaluable in improving target accuracy and preventing complications with this approach. The approach has been used in the treatment of trigeminal neuralgia as well as in performing biopsies of lesions located in the parasellar region, described formerly by the senior author (M.S.). A comprehensive cadaveric study of the region traversed by needle is thus presented.

MATERIALS AND METHODS

Three cadaveric heads (six sides) were fixed in formaldehyde and injected with latex. A detailed description of the regional anatomical needle trajectories was performed.

RESULTS

An "inverted pyramid" subdivided into three segments is described. The inferior third begins at cutaneous penetration and ends at the parotid duct (PD). The middle third extends from the PD to the lateral pterygoid muscle (LPM). The superior third starts from the LPM and ends at the FO. The main vascular anatomical variation was with regard to the maxillary artery (MA). In half of the cases, the MA traveled though the middle of the pyramid and in the other half through the upper third.

CONCLUSIONS

Although widely used, the FO approach carries risks. Special attention is warranted when the needle traverses the upper third of the pyramid to avoid the variant course of the MA. Image-guided techniques and detailed anatomical knowledge are necessary to expand the use of this route not just for approach to lesions within the parasellar and upper third of the petroclival region but also to lesions invading the infratemporal fossa.

A very rare complication of acute sinusitis: subgaleal abscess

A 12-year-old girl presented with a swollen right eye with three days of pain and a diffused swollen frontal region and head lasting for one day. On the computed tomography with contrast, diffused collection was detected in the subgaleal regions and subperiosteal of the right orbita. It was observed that she had bilateral maxillary, ethmoidal, and frontal sinusitis and an infected bilateral middle concha bullosa in the right side. No symptoms of intracranial complication and osteomyelitis in the frontal or other calvarial bones were determined. This case presentation is thought to be the first one in literature that is an acute sinusitis without an intracranial complication and osteomyelitis, but with a diffused subgaleal abscess resulting from a subperiosteal abscess.

Peripheral osteoma of the zygoma: literature review and case presentation

Osteoma is a benign, bone forming tumor that is uncommon in the jaws. The aetiology of osteomas is unknown but trauma, infection and developmental abnormalities have been implicated. Solitary osteoma may be classified as peripheral, central and extraskeletal, while multiple osteomas may be associated with Gardner's syndrome. We report a case of solitary peripheral osteoma of the zygoma with a review of literature.

Osteoid osteoma of the zygoma: report of an unusual case

BACKGROUND

Osteoid osteoma is a benign tumor of bone characterized by pain, usually occurring at night, that shows a dramatic response to aspirin. The literature contains reports of only a few cases in the head and neck region.

CASE DESCRIPTION

The authors present an unusual case of an osteoid osteoma of the craniofacial bones. The patient sought an evaluation of pain in the area of the right zygoma. One of the authors, an oral and maxillofacial surgeon, noted a small area of swelling. The patient underwent radiographic, computed tomographic and nuclear medicine studies. On the basis of the images and the biopsy report, the authors made a diagnosis of osteoid osteoma. In this article, they describe the treatment of and new modalities of therapy for this condition.

CLINICAL IMPLICATIONS

The general dentist should be aware of any lesion that is not common. If the generalist has any doubt about the nature or management of an unusual oral lesion, referral to appropriate specialists is mandatory.

Tumoral mass presenting in the nasomalar region arising from the lateral nasal wall: pleomorphic adenoma

Pleomorphic adenoma is the most common benign salivary gland tumor. Although the major salivary glands are the most common sites of its origin, it can also occur in the minor salivary glands of the oral cavity and rarely in the neck, ear, nasal cavity and larynx. We report a rare case of intranasal pleomorphic adenoma arising from lateral nasal wall and discuss the clinical presentation, diagnosis and treatment approaches with the review of the literature.

Contour Restoration of the Secondary Deformities of Zygomaticoorbital Fractures With Porous Polyethylene Implant

Inappropriate treatment or untreated fractures of the zygomaticoorbital area results in secondary deformities such as loss of malar projection, enophthalmos, and dystopia. Secondary deformities can be corrected with osteotomies, contour restoration, or a combination of both. Contour restoration can be performed with using onlay grafting with autogenous material or alloplastic implants. In this study, mild to moderate secondary deformities of zygomaticoorbital fractures were corrected with porous a polyethylene implant, which is a highly biocompatible, durable, and stable material. The number of patients who have no surgical treatment at the time of their initial injury was 15, whereas the number of patients who have an initial treatment that resulted in secondary deformities was seven. Twelve of 15 patients had only loss of cheek projection and three of the 15 patients had dystopia and loss of cheek projection. The remaining seven patients had secondary deformities resulting from skeletal surface contour abnormality as a result of comminuted fractures. In 17 of the patients, we used a subciliary approach while using the old incision scar for access in the remainder. In 22 patients, 24 implants were used. Porous polyethylene implant was carved outside in according to the existing contour deficit and was placed in the subperiosteal plane and fixed with titanium screws. The mean follow-up period was 13 months (range, 6-24 months). In this follow-up period, there was no implant extrusion, exposition, infection, or any complication resulting from subciliary incision. Patients were satisfied with the results. The best result can be achieved with porous polyethylene implant in contour restoration of mild to moderate secondary deformities of zygomaticoorbital fractures. The use of this implant in the zygomaticoorbital area is safe and has minimal morbidity.

The Effects of Masseter Muscle Paralysis on Facial Bone Growth

BACKGROUND

Understanding the effects of muscle function on facial bone growth may help us treat children with facial anomalies. Facial bone growth is known to be a result of both genetic and epigenetic influences. One of the main epigenetic factors controlling growth is thought to be muscle action. The purpose of this study was to establish a model of single facial muscle paralysis and to identify the effects masseter muscle paralysis has on mandible and zygoma growth.

METHODS

Twenty New Zealand white rabbits were divided into control, paralysis, and sham groups. Masseter muscle paralysis was achieved with botulinum toxin A (BTX). Computed tomographic and single-photon emission computed tomography (SPECT) scans and cephalometric measurements were performed. Masseter weights and mandible and zygoma volumes, shapes, and metabolism were measured.

RESULTS

Eighteen animals completed the study. Significant decreases in zygoma and mandible volumes with minimal changes in shape were seen on the paralyzed sides. SPECT showed a decrease in bone production in both zygomas and mandibles on the paralyzed sides.

CONCLUSIONS

An animal model has been created in which the effects of single muscle paralysis on bone growth can be studied. Masseter muscle function may be responsible in maintaining mandible and zygoma volume by controlling bone production. Masseter function alone has less influence on mandible and zygoma shape.

[Melanotic schwannoma of the temporozygomatic region]

INTRODUCTION

Melanotic schwannoma is a rare benign tumor, which arises from nerve sheath cells. Melanotic differentiation is its most histologic characteristic.

CASE REPORT

We report a case of melanotic schwannoma arising in the temporozygomatic region for a man of 38-year-old. Outcome was favourable after tumor resection.

DISCUSSION

This benign neoplasm occurs pronominally in spinal nerve roots. Craniofacial locations are rare. Most melanotic schwannomas are slow growing tumors, but prognosis can be poor because of local recurrence or malign behavior, especially when multiple lesions are present and/or involve the Carney complex.

Choroidal melanoma metastasizing to maxillofacial bones

Background

Melanomas are malignant neoplasm of melanocytic origin, commonly seen on skin and various mucous membranes. Melanomas are the commonest intraocular malignant tumour in the adults.

Case presentation

A 50-year-old female presented with complains of painless progressive swelling in right cheek region of two months duration. Examination revealed a 6 × 4 cm bony hard swelling in right zygomatic region near and below lateral canthus of right eye with loss of vision. Investigations revealed it to be a choroidal melanoma metastatising to the zygomatic bone. Patient was successfully treated by surgery.

Conclusion

Choroidal melanoma, which commonly metastasizes to liver and lungs, never involves the lymph nodes and metastasis to facial bones is rare. Here we report a case of choroidal melanoma metastasizing to maxillofacial bones.

Forensic value of gunpowder tattooing in identification of multiple entrance wounds from one bullet

Multiple entrance gunshot wounds can give useful information in forensic evaluation of deaths from homicide and suicide. Although the presence of multiple entrance gunshot wounds does not absolutely exclude the possibility of suicide, they are important to the forensic investigators and pathologists in cases of assault, attempted homicide and suicide as they provide important clues for determination of number of shots fired and direction of firing. We present a case of 16 years of young woman who was shot to death by her husband. External examination revealed an entrance wound with semi-lunar shot residue at the dorsal side of her left hand at 5th metacarpus, and exit wound on the hypothenar muscle. There was also a second wound entrance located on her left zygoma. Direction of the bullet was downward traveling from left-to-right. Initially it was thought that there were two close shots, but when her left hand was placed over the malar area her face, it was determined that the gunshot powder tattoos were completing the nature of a single shot from a close distance. Crime scene investigation revealed only one cartridge casing. The autopsy and radiography findings showed that the bullet was entered from dorsal site of the left hand exiting from the palm and re-entering from the zygomatic region, hit the base of the skull, and remained in the soft tissue of the right mandible after passing the soft palate. The bullet was caused an incomplete laceration of the right internal arteria carotid and she died of internal and external bleeding. Detailed investigation of gunshot residues can provide important information for clarification of close distance gunshot wounding. We present this case due to its interesting nature, and to highlight the importance of detailed investigation of the gun powder residues in cases with multiple entry wounds.

The value of postoperative radiographs in the management of zygomatic fractures: Prospective study

It is customary in maxillofacial surgical practice for all patients who have undergone open reduction and or fixation of a fracture of the zygomatic complex to have postoperative radiographs taken before they are discharged. These radiographs are often not reviewed before the patient's departure and in many cases have no bearing on the patient's management. We prospectively reviewed over a 3-month period all patients who were treated for fractures of the zygomatic complex and had no postoperative radiographs. None of these patients had to return to the operating theatre for a further operation, which emphasises the lack of clinical evidence to support routine postoperative radiography in the management of fractures of the zygomatic complex.

[Ganglioneuroma of the zygoma]

INTRODUCTION

Ganglioneuroma is an uncommon benign tumor that arises from the sympathetic nervous system accounting for less than 1% of all soft-tissue neoplasms.

CASE REPORT

We report the case of a 22 year-old man who presented a ganglioneuroma localized in the zygoma.

DISCUSSION

Ganglioneuroma generally develop in the abdomen or thorax soft tissue. The occurrence of ganglioneuroma in the bone is exceptional. To date less than ten cases have been reported, six of which involved the mandible. We discuss the possible causes of tumor development at this site.

Prominent Premalar and Cheek Swelling: A Sign of Thyroid-associated Orbitopathy

PURPOSE

To describe prominent premalar and cheek swelling as a previously undescribed clinical feature of thyroid-associated orbitopathy (TAO).

DESIGN

Retrospective interventional case series.

METHODS

A retrospective case review of patients with prominent premalar and/or cheek swelling and TAO was undertaken. All patients who presented from March 2002 to February 2005 with complaints of premalar and/or cheek swelling in TAO were analyzed.

RESULTS

Six female patients between the ages of 28 and 66 years (average, 44.2 years) who had complaints of prominent premalar and/or cheek swelling and TAO were included in the study, among 326 new patients with TAO (incidence: 1.84%). Five of the 6 patients had Graves hyperthyroidism. One initially had Hashimoto thyroiditis, which converted to Graves hyperthyroidism. In all cases, TAO preceded the thyroid disease or developed simultaneously (average time from TAO to thyroid disease was 3.0 months). No patient had received corticosteroids before premalar and/or cheek swelling. The premalar and/or cheek swelling was bilateral in all cases, but 2 of 6 were asymmetric. No diurnal fluctuation or tenderness in premalar and/or cheek swelling was noted. All improved incompletely over several months. Brow, eyelid swelling, and orbital-fat hypertrophy on radiologic examination was coincidentally noted in 5 of 6 cases. Pretibial myxedema was noted in one case. One case was associated with another autoimmune disease (rheumatoid arthritis).

CONCLUSIONS

Prominent premalar and cheek swelling should be considered among the clinical features of TAO. The true incidence will become apparent as we question and examine patients more carefully regarding this entity and as we review premorbid photographs.

Primary intraosseous hemangioma of the orbit: an unusual presentation of an uncommon tumor

CASE REPORT

An asymptomatic patient was referred for assessment of an intraocular amelanotic mass in her left eye. Examination showed a mass effect in the inferior location at the 5 o'clock position. This abnormality was defined with ultrasound biomicroscopy and standard ultrasound, but because the appearance was not typical of a melanoma or other choroidal infiltrate, magnetic resonance images and computed tomograms of the orbits were obtained, identifying an extraocular mass arising from the zygomatic rim. Results of a biopsy reported an intraosseous hemangioma.

COMMENTS

The diagnosis of intraosseous hemangioma, because of its low incidence and unusual manner of presentation, can be challenging. Computed tomography and biopsy are helpful in making a definitive diagnosis.

Chondromyxoid fibroma of the zygoma: a case report

Chondromyxoid fibroma is a rare benign tumour of chondral origin. It usually involves the long bones of the lower extremity, whilst involvement of craniofacial skeleton is extremely unusual. The second case of chondromyxoid fibroma of the zygoma described in literature is presented and the surgical resection of the lesion with tumour-free margins as the key factor for avoiding local recurrence of this tumour is emphasised.

Quantifying Positional Plagiocephaly

The treatment of positional plagiocephaly is controversial. A confounding factor is the lack of a proven clinically viable measure to quantify severity and change in plagiocephaly. The use of anthropometric measurements is one proposed method. In this study, the reliability and validity for this method of measurement were investigated. Two clinicians independently recorded caliper measurements of cranial vault asymmetry (CVA) for infants referred for plagiocephaly or torticollis, and an unbiased observer recorded visual analysis scores during the same visit. CVA scores were assigned into three predetermined severity categories (normal CVA < 3 mm, mild/moderate CVA <or= 12 mm, moderate/severe CVA > 12 mm). CVA measurements and visual analysis scores were recorded for 71 and 54 infants, respectively. Intrarater reliability was established (kappa = 0.98, kappa = 0.99), but inter-rater reliability was not (kappa = 0.42). In addition, the inter-rater reliability for the severity categories based upon these measures was poor (kappa = 0.28) and failed to correlate to the visual analysis (kappa = 0.31). Development of a stable and meaningful measurement system for the extent of plagiocephaly is needed to allow scientific studies of the natural history of plagiocephaly and effectiveness of interventions.

The value of three-dimensional computed tomography in diagnosis and management of Jacob's disease

This study reports a case of Jacob's disease characterized with limited mouth opening due to bilateral coronoid hyperplasia forming pseudojoints with zygomatic arches. Magnetic resonance (MR) examination of temporomandibular joint (TMJ) is usually the imaging method chosen in patients with such symptoms. However, the coronoid processes can not be displayed because they are not included in field of view in MR imaging of TMJ. For that reason, these patients may be treated for a misdiagnosis of TMJ disorders. In this study, the aetiology and diagnostic methods of Jacob's disease, the pre-operative/post-operative role of three-dimensional computed tomography and some measurements used in diagnosis were evaluated.

Zygomatic osteotomy for resection of medial temporal cavernous angioma in dominant hemisphere after subdural grid electroencephalographic study

We report the treatment of a patient suffering from intractable epilepsy caused by a large cavernous angioma in the hippocampus of his dominant hemisphere. Surgical removal of a lesion and epileptic focus located in the surrounding brain tissue significantly improves seizure conditions. However, total removal of a large cavernous angioma in the medial temporal structure of dominant hemisphere is occasionally difficult because of the depth of the lesion and its contiguity with eloquent brain structures. Furthermore, when an intracranial electrocorticogram with grid electrodes is adopted, swelling of soft tissue caused by the initial operation for the installation of the grid electrodes narrows the operative view obtained by conventional frontotemporal craniotomy. We added a zygomatic osteotomy to the operative procedure for the present patient, and this enabled us to push soft tissue down and away from the operative field to provide a wider operative corridor through which total removal of the lesion and epileptic focus was accomplished. The patient has had a favorable postoperative course without suffering any seizure for 4 years.

Oromaxillofacial osseous abnormality in Sturge-Weber syndrome: case report and review of the literature

We report a case of a 17-month-old child affected by Sturge-Weber syndrome who had unusually rapid overgrowth of the left frontal, temporal, orbital, and maxillary regions. CT angiography illustrated osteohypertrophy with periostitis and associated soft tissue hypertrophy directly corresponding to the distribution of the cutaneous port-wine stain. Extended maxillectomy was performed because of rapid growth and clinical debilitation, with surgical pathology revealing juvenile ossifying fibroma.

Combined push-pull distraction for correction of syndromic midfacial hypoplasia

PURPOSE

Gradual midfacial advancement, applying the principle of distraction osteogenesis, reduces the restriction of the soft tissues and results in bony consolidation without need for grafting. The midface can be distracted by either pushing it forward, using semiburied devices, or pulling it forward by a rigid external device. For each method there are inherent technical problems, such as controlling the vector of movement, symmetry of advancement, and differential movement of the upper/lower face. We have used a combination of the 2 methods, called "push-pull," in an effort to control the distraction process. The purpose of this paper is to describe our push-pull distraction technique and summarize our early experience.

MATERIALS AND METHODS

Ten patients (5 males and 5 females) with a mean age of 11 years 2 months underwent midfacial advancement using push-pull distraction. Two orthodontists, blinded for landmark identification, traced preoperative and postoperative cephalograms and determined linear and angular measurements of midfacial position. A Student t test was used to assess differences between the cephalometric measures on the 2 radiographs. Interexaminer reliability was calculated by an intraclass correlation coefficient.

RESULTS

Postdistraction cephalograms were taken a mean of 10 months (range, 3 to 20 months) after removal of the devices. Patients exhibited improvement at all levels of the midface after distraction. There was a statistically significant sagittal advancement from the infraorbital rim to dentoalveolus. The central midface was sufficiently advanced as shown by an improved convexity, nasolabial angle, and upper labial protrusion. There were no significant differences between examiners for any of the measurements in this study.

CONCLUSIONS

Push-pull distraction permits 1) equal movement at both the upper and lower facial levels, 2) advancement of the central midface, and 3) symmetric movement of the zygomaticomaxillary complexes. This method also provides a backup, in case one device malfunctions. In combination, the advantages of each device are additive; whereas the weaknesses are not. The push-pull technique is a practical method for midfacial distraction until a better single device is fabricated.

[A case of advanced granuloma eosinophylicum maxillae]

INTRODUCTION

We present a case of an advanced granuloma eosinophilicum of maxillary location in a 76 years old man who was admitted to our Department with symptoms of chronic pain in right zygomatic region.

MATERIAL AND METHOD

We want to lay emphasis on long lasting, low symptomatic development of this kind of tumor and to insist on very carefull otorhinolaryngological and as well radiological examination.

RESULTS

According to literature there are many methods used in the therapy of such cases begining with operations, through radiotherapy, the use of steroids or cytostatic drugs and also different combinations of mentioned possibilities. In our case we applied an operation without further radiotherapy and didn't observe any symptoms of recurrence so far.

CONCLUSIONS

Granuloma eosinophilicum and its multifocal variety e.i. Hand-Schueller-Christian disease require different patterns of treatment depending on its location, tendency to recurrence and the age of affected person.

[Aneurysmal bone cyst of the temporal and zygomatic region]

Aneurysmal bone cyst are commonly seen in long bone and vertebrae. There are rare in skull bones especially in the temporal bone and zygomatic arch. We report one case in a young male of 15 years old. The main symptom was swelling of the temporo mandibular region. Clinical, radiological and therapeutic aspects of the disease are discussed with regards to the literature. The diagnosis is based on good imaging and histopathological analysis. Surgical removal is the main treatment.

[Aneurysmal bone cyst of the maxilla. Report of one case]

Aneurysmal bone cysts are benign fibro osseous lesions, rarely present in maxillary region. We report the CT and morphological findings of aneurysmal bone cyst of the maxilla in a 15 years old female. The patient was subjected to a maxillectomy, preserving the orbit floor. The postoperative evolution has been uneventful. The tumor mainly involved the maxillary sinus with extension to the orbit wall and osseous palate. Very few cases of aneurysmal bone cysts of the maxilla have been reported in the literature.

Primary tuberculous osteomyelitis of zygoma

Osteomyelitis of zygomatic bone is rare, and tuberculous osteomyelitis is even rarer. This is the case report of a 3-year-old child presenting with a discharging sinus and swelling on the zygoma, which was initially thought to be orbital cellulitis. After further examination, she was diagnosed as having tuberculosis of zygoma and responded to anti-tubercular chemotherapy.

Cavernous hemangioma of the bony orbit

PURPOSE

To study the clinical features, diagnosis and management of intraosseous cavernous hemangioma of the orbit.

METHODS

Five cases of intraosseous cavernous hemangioma seen in our hospital from Jan 1, 1986 to Dec 31, 2000 were reviewed.

RESULTS

Among all five cases, two were male and three were female. The mean age was 47.6 years old, ranging from 39.0 to 55.0 years. The left orbit was affected in 4 cases and the right one in 1 case. The bony involvement occurred in frontal bone (two cases), zygomatic bone (two cases) and sphenoid bone (one case). A painless, slowly enlarging hard bony mass fixed to the bone with no pulsations was the main clinical sign. The x-ray and CT appearance of intraosseous cavernous hemangioma of the orbit were characteristic and usually diagnostic. The differential diagnosis of it included fibrous dysplasia, eosinophilic granuloma, multiple myeloma and metastatic carcinoma. Treatment is local removal of the bone containing the tumor.

CONCLUSIONS

Intraosseous cavernous hemangioma is a rare tumor of the orbit and usually has good surgical result.

[A histological study of three-dimensional external zygomatic suture distraction osteogenesis]

OBJECTIVE

To explore the histological change in suture of zygomatic bone for the zygomatic suture direct distraction osteogenesis.

METHODS

The zygomatic bone was distracted by 3-D external distraction appliance without osteotomy. The specimens were taken 1, 3, 5 and 8 weeks after, and then examined histologically and compared with the blank contralateral side.

RESULTS

There were lots of fibroblasts, osteoblasts and capillary vessels in the distracted suture tissues one week after distraction, and the fibers were observed to connect the sides of suture and arranged orderly. The surfaces of the expanded suture were irregular. Bone formation was active in the expanded side. The bone trabeculae were mature and oriented in the direction of distraction in the distracted sides at 3 weeks. A great amount of new woven bones were found in 5-week specimen. New bones were formed completely 8 weeks after the distraction.

CONCLUSIONS

New bone formed rapidly in the distracted side of zygomatic bone under suture distraction osteogenesis without osteotomy.

Cranial Distraction for Plagiocephaly: Quantitative Morphologic Analyses of Cranium Using Three-Dimensional Computed Tomography and a Life-Size Model

The aim of this study was to analyze the morphologic changes of the craniofacial skeleton in synostotic plagiocephaly after cranial distraction. Preoperative and postoperative computed tomography scans were taken, and three-dimensional reconstruction was then performed. Three measurements were obtained: intracranial volume, volume of the middle cranial fossa, and length of the zygomatic arch. Intracranial volume reached values that were normal for a 2-year-old child postoperatively, and the discrepancy between left and right half volumes decreased over time. The discrepancy of the volume of the middle cranial fossa also decreased after surgery, and the asymmetry of the zygomatic arch improved significantly. Based on these objective findings, the authors believe that cranial distraction could favorably affect craniofacial dysmorphology of synostotic frontal plagiocephaly.

Métastases multiples d’un améloblastome mandibulaire

INTRODUCTION

Ameloblastoma is a benign odontogenic tumor which can be locally aggressive and invasive. Metastases are rare but possible and must be considered as a malignant form of the tumor.

OBSERVATION

A 50-year-old woman presented a jugal metastasis of a mandibular ameloblastom which had been treated several times 28 years earlier. Six months after resection of the metastasis, the patient developed multiple cervical node metastases which were removed by radical curettage. Five months later, new metastases developed on the scalp and three months later a voluminous metastasis involving the right hemiface extended to the base of the skull. Surgical resection was only partial followed by radiotherapy. Ten months later the outcome was favorable.

DISCUSSION

The absence of any histological sign of malignity in the primary tumor and in the metastases, as observed in our patient, is remarkable. Metastases generally develop in the lung (61-80% of cases). Metastases to the scalp have never been described. The time to development of a metastasis is generally very long and metastases usually remain asymptomatic. Progression is very slow, like for the primary tumor. Several factors predictive of metastasis have been described: female gender, age at onset of primary tumor (2nd to 3rd decade) and multiple local recurrences. There is no standard treatment for metastases. Chemotherapy is not effective. Radiotherapy may be effective, particularly when lesions are not accessible to surgery. Surgical resection remains the treatment of choice.