A new application of a screw-plate for prosthetic reconstruction after bilateral total maxillectomy

Satisfactory functional and aesthetic rehabilitation of a patient after total bilateral maxillectomy is a great challenge to the surgeon and prosthodontist. A particular problem is support and retention of the obturator. In the case described, the problem was solved by attaching the prosthesis with finger clasps to a classic AO-reconstruction plate anchored rigidly with screws to both zygomata. The results in terms of mastication, swallowing, phonation and aesthetics were satisfactory for more than 2 years, when the patient died from brain metastasis and pneumonia. The technique seems promising and merits further study using titanium screws and plates.

Madelung's disease (benign symmetric lipomatosis)

Madelung's disease, benign symmetric lipomatosis, is a rare disease of undetermined cause characterized by symmetric deposits of diffuse adipose tissue on the cheeks, the neck, and the upper trunk. This article outlines our experience with four patients and presents a case report of a specifically remarkable affectation that agrees with previous data linking male alcoholics with this disease. The treatment in all cases was palliative surgical removal of excess fat from the neck and paracervical regions.

In situ DNA hybridization analysis of human papillomavirus (HPV) sequences in benign oral mucosal lesions

A series of 144 surgically treated benign oral mucosal lesions were analysed using an in situ DNA hybridization technique with 35S-labeled human papillomavirus (HPV) DNA probes to demonstrate the DNA of HPV types 6, 11, 13, and 16, in routinely processed, paraffin-embedded biopsy specimens. These lesions and an additional 62 benign oral mucosal biopsy specimens (total, 206 specimens) were also assessed by the indirect immunoperoxidase (IP-PAP) technique to detect the expression of HPV structural proteins (viral antigens). A total of 54/206 (26.2%) lesions were observed to express HPV antigens, being found in 45/92 (48.9%) of the squamous cell papillomas/condylomas, in 1/54 fibrous hyperplasias, in 1/8 true fibromas, and in 7/8 (87.5%) of the focal epithelial hyperplasia (FEH) lesions. Of the HPV DNA-positive lesions, 15/45 (33.3%) expressed HPV antigens, the expression not being related to any particular HPV type. HPV DNA sequences were found in 45/144 (31.3%) of the lesions. HPV DNA was present with the highest frequency in FEH (83.3%), followed by the papilloma/condyloma group (33.8%), papillary hyperplasia (28.6%), fibrous hyperplasia (24.4%), and true fibromas (14.3%). The most frequent HPV type was HPV 11, representing 37.8% of the DNA-positive lesions. HPV 13 DNA, previously regarded as specific to FEH, was disclosed as a single HPV type in seven cases, and as a double infection by HPV 11 and 13 in an additional three cases, including all five morphologically distinct entities. Noteworthy is the discovery of the high-risk HPV type 16 DNA in 17.8% of the DNA-positive lesions, four papilloma/condyloma lesions, three fibrous hyperplasias, and one FEH.(ABSTRACT TRUNCATED AT 250 WORDS)

Detection of human papillomavirus DNA in oral mucosal lesions using in situ DNA-hybridization applied on paraffin sections

The in situ DNA hybridization technique, carried out under stringent conditions, was used to detect human papillomavirus (HPV) DNA of types 6, 11, and 16 in paraffin sections of 32 surgically treated oral mucosal lesions. Expression of HPV structural proteins was analyzed by means of the immunoperoxidase (IP-PAP) method. A total of 10 (31.3%) of the 32 lesions proved to express HPV antigens, which were found in 4 of 7 squamous cell papillomas, in 2 of 2 classic condylomas, in 2 of 10 papillary hyperplasias, and in 2 of 3 leukoplakia lesions. Two of the squamous cell papillomas contained HPV 6 DNA, and 4 additional lesions were positive for HPV 11 DNA. In one of the condylomas, a double infection by HPV 6 and 11 was found, while the second was positive for HPV 11 alone. Both the HPV antigen-positive papillary hyperplasias contained HPV 6 DNA, as did the HPV antigen-positive leukoplakia lesions. Of the latter, one was infected by HPV 6 and 11. DNA of the "high-risk" HPV 16 was contained in two lesions: one lichen planus lesion and one of the two squamous cell carcinomas. The results confirm the previously reported evidence of HPV involvement in oral mucosal lesions. The implications of these findings are discussed in terms of the well-established premalignant character of oral leukoplakia and oral lichen planus, although far less commonly versus leukoplakia, with special emphasis on the discovery of the "high-risk" HPV 16 in the latter as well as in oral cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of malignant myxoma (myxosarcoma) of the maxilla

A centrally located maxillary myxoma with malignant histologic appearance and aggressive clinical course is reported in a 40-yr-old man. The gelatinous polypoid tumor mass was diagnosed as a myxoma in the first biopsy. The tumor recurred rapidly (within 3 wk) eroding the bony structures of the maxillary sinus and the hard palate and infiltrating the adjacent soft tissues. In repeated biopsy (as well as reassessment of the first biopsy) the tumor was found to be composed of plump stellate cells, some of which were pleomorphic with atypical and bizarre mitotic figures. The amorphic myxoid matrix contained acid mucopolysaccharides and was completely devoid of lipids. Electron microscopy demonstrated that the tumor cells were identical to fibroblasts, which is consistent with the appearance of myxoma cells. When radiotherapy was unsuccessful, we removed the left maxilla with orbital excenteration and reconstructed the jaw. Three years later the patient died accidentally. At autopsy, no recurrence of myxoma or distant metastases were found. Due to the malignant histologic appearance and the aggressive clinical course, this tumor can be called an odontogenic myxosarcoma and should be added to the WHO classification as a malignant variant of odontogenic myxoma.

Immunohistochemical demonstration of human papilloma virus (HPV) antigens in oral squamous cell lesions

Six oral squamous cell tumours classified as focal epithelial hyperplasia (FEH), Condyloma acuminatum (CA) and squamous cell papilloma (SQP) were subjected to indirect immunoperoxidase staining with anti-human papillomavirus (anti-HPV) antiserum to demonstrate the possible presence of HPV antigens in these lesions. The results are discussed in the light of the observations on HPV-lesions elsewhere in the body (in uterine cervix), and a suggestion is made to adopt the name condyloma for all those tumours where HPV aetiology can be established by ultrastructural or immunohistochemical means.

Extra-articular fibrous ankylosis of the mandible after zygomatic fracture

Zygomatico-coronoid fibrous ankylosis of the mandible is a complication which rarely occurs if fractures of the middle third of the facial skeleton have been adequately treated. 379 zygomatic fractures in hospitalized patients were treated at the Department of Jaw Surgery of the Surgical Hospital in Helsinki between 1969 and 1975. 36 cases were characterized by convalescence being complicated by significant restriction of jaw opening. 25 patients were successfully treated by physiotherapy and 6 other by a forced opening of the jaws under general anaesthesia. In the remaining 5 cases 91.3% of the fractures) the clinically verified fibrous extra-articular ankylosis was resistant to the above mentioned conservative methods and was treated instead by intraoral coronoidectomy, supplemented in one instance by a partial myotomy of the affected masseter muscle. The importance of prophylactic physiotherapy is stressed and applies to both the post-accident and the post-corrective-operation period.

Fatality from central hemangioma of the mandible

Fatalities from central hemangiomas, including a new case, are reviewed. The importance of a thorough examination of young patients with suspicious gingival bleeding and mobile teeth before extraction is emphasized. The nature of the lesion and the methods of treatment are discussed. In the case reported, there were arteriovenous malformations in the soft tissues surrounding the mandible and a seemingly separate central mandibular lesion. The latter showed rapid growth throughout the mandible, ending fatally after spontaneous bleeding and extraction of the mandibular third molar. During the preceding three years, bilateral external carotid ligation had been performed and numerous conservative measures had been taken, including corticosteroid therapy, injections of Sotradecol, and telecobalt irradiation, all with little benefit.

Closed condylotomy in the treatment of recurrent dislocation of the mandibular condyle

Twenty-one patients 10-79 years of age were operated on for recurrent dislocation of the mandibular condyle using Kostecka's closed condylotomy method. The procedure alters the condyle position and will indirectly shorten the lateral pterygoid muscle, thus eliminating its pulling power to the condyle, even though it still functions. For the study, a late examination was performed with at least 1 year's follow-up. Seventeen patients were cured after unilateral or bilateral condylotomies, and two patients were asked to undergo a second operation on the opposite side. In normal cases any joint operated on was cured. Two cases suffering from congenital torticollis or disseminated sclerosis were felt to be unsuccessful. One exceptional case resulted in a pseudarthrosis, and was repaired by rib bone cartilage transplant. The method is the simplest and least traumatic when recurrent dislocation of the temporomandibular joint is treated surgically.

Transosseous wiring in the treatment of condylar fractures of the mandible

During 1973-1975, 27 patients with condylar fractures at the lower or middle level were operated on via the submandibular approach; 5 patients were under 14 years of age. The condyles were medially dislocated or severely displaced, leading to malocclusion. Various kinds of transosseous wirings were used and the mean time of intermaxillary fixation was 22.6 days. The follow-up study of the 27 patients was made on average 11.6 months after the operation. Postoperatively the mouth opening averaged 41.5 mm. There was a slight deviation of the chin (mean 2mm) to the operated side in half the cases. Lateral excursions were within normal limits. Slight motor weakness in the lower lip on the operated side was noted in 3 cases and mild pain in the operated joint in 8 cases. A radiograph revealed some shortening of the condyle in most cases, and some kind of angulation, mostly posterior, in half the cases. No tendency to ankylosis was found and totally normal and symmetric function of the joints was noted in 24 cases. In the light of the results of this follow-up study the method presented, which is not a very easy one, seems to be useful.

Skeletal anomalies and keratocysts in the basal cell nevus syndrome

Five cases with multiple jaw cysts from two families, and two other unrelated patients are presented. Multiple keratocysts of the jaws were found in all patinets whose cysts had been examined histologically. There were also several follicular cysts without keratinization. In some cysts there was even a pronounced proliferation of the basal cells, which resembled basal cell carcinoma. Basal cell carcinomas were seen in only three patients, apparently because the series had been selected for the presence of multiple jaw cysts. However, two patients with only pigmented nevi showed a marked proliferation of the basal cells. An elevation of serum alkaline phosphatase was noted in four out of five patients. The sella turcica was bridged in all but one patient and fusion of the vertebrae was seen in all but two patients. In addition, a high frequency of rib anomalies, frontal and parietal bossing, mild mandibular prognathism and dural calcification was seen. Therefore, what is called the basal cell nevus syndrome may be regarded as a skeletal dystrophy syndrome. Based on the family pedigrees, an autosomal dominant inheritance with poor penetration seems probable.