Mandibular Coronoid Process Displacement: Signs, Causes, Treatment

Open-mout h locking due to lateral impingement of the mandibular coronoid process, lateral to the zygomatic arch, is described in five dogs and one cat. In order to elucidate the underlying cause of this abnormality, radiographs of temporomandibular joints of forty dogs, as well as the case history of a human patient, are compared. Three possible aetiologies are given, namely, flattening of the zygomatic arch, aberrant architecture of the condylar aspects, or contracture of the pterygoid muscle. An effective surgical treatment to prevent recur-rence of coronoid impingement was achieved by ostectomy of the locking part of the coronoid process.

Unilateral protrusion of the mandible is described as a veterinary and comparative abnormality in five dogs, a cat and a woman. For the impingement of the coronoid process lateral of the zygomatic arch causing open-mouth locking in the animals, three aetiologies and an effective ostectomy of the coronoid process are given.

Long-term mid-facial growth of patients with a unilateral complete cleft of lip, alveolus and palate treated by two-stage palatoplasty: cephalometric analysis

OBJECTIVES

The aim of this study is to evaluate long-term facial growth in adults previously treated for an isolated unilateral complete cleft lip, alveolus and palate by two-stage palatoplasty.

MATERIALS AND METHODS

Unilateral cleft lip and palate (UCLP) patients of 17 years and older treated by two-stage palatoplasty were invited for long-term follow-up. During follow-up, lateral cephalograms were obtained (n = 52). Medical history was acquired from their medical files. Outcome was compared to previously published normal values and the Eurocleft study.

RESULTS

Soft and hard palate closure were performed at the age of 8 (SD 5.9) months and 3 (SD 2.2) years, respectively. The mean maxillary and mandibular angle (SNA, SNB) were 74.9° (SD 4.2) and 75.8° (SD 3.8). Maxillary and maxillomandibular relationships (SNA, ANB) were comparable to all Eurocleft Centres, except for Centre D. We observed a significantly steeper upper interincisor angle compared to the Eurocleft Centres.

CONCLUSIONS

This study describes the long-term craniofacial morphology in adults treated for a UCLP with hard palate closure at a mean age of 3 years. The mean maxillary angle SNA and mandibular angle SNPg were comparable to previous studies both applying early and delayed hard palate closure. The observed upper incisor proclination is likely caused by orthodontic overcorrection in response to the unfavourable jaw relationships. No clear growth benefit of this protocol could be demonstrated.

CLINICAL RELEVANCE

The present study shows the long-term craniofacial morphology of UCLP adults after the Utrecht treatment protocol which includes two-stage palate closure.

Intratumoral injection of radioactive holmium ( 166 Ho) microspheres for treatment of oral squamous cell carcinoma in cats

BACKGROUND & AIMS

A "microbrachytherapy" was developed as treatment option for inoperable tumours by direct intratumoral injection of radioactive holmium-166 ( ¹⁶⁶ Ho) microspheres (MS). ¹⁶⁶ Ho emits β-radiation which potentially enables a high, ablative, radioactive-absorbed dose on the tumour tissue while sparing surrounding tissues.

MATERIALS & METHODS

Safety and efficacy of ¹⁶⁶ Ho microbrachytherapy were evaluated in a prospective cohort study of 13 cats with inoperable oral squamous cell carcinoma without evidence of distant metastasis.

RESULTS

Local response rate was 55%, including complete response or partial response (downstaging) enabling subsequent marginal resection. Median survival time was 113 days overall, and 296 days for patients with local response. Side effects were minimal. Tumour volume was a significant predictor of response.

DISCUSSION

Response rate may be further improved by optimizing the intratumoral spatial distribution of ¹⁶⁶ Ho MS.

CONCLUSION

¹⁶⁶ Ho microbrachytherapy has potential as a minimally invasive, single procedure radio-ablation treatment of unresectable tumours with minimal morbidity.

Management of the premaxilla in the treatment of bilateral cleft of lip and palate: what can the literature tell us?

Objective

In the treatment of bilateral cleft lip and palate (BCLP) patients, there is discussion about the management of the position of the premaxilla. This literature analysis summarises the literature on managing this condition.

Materials and methods

A PubMed, Embase and Cochrane Library search was conducted resulting in 4465 articles which were screened on title and abstract.

Results

Seventy-one articles were available in full text, 16 of which were included in this literature analysis. We searched on keywords timing and technique, complications, growth of the maxilla and results after bone grafting the alveolar process. This literature analysis has shown that there are various ways to correct the position of the premaxilla. These can be divided into primary, early, late secondary and tertiary intervention before the age of 8 years, between the ages of 8 and 12 years and older than 12 years. Correction is done with surgery, orthodontics or a combination, with or without bone grafting.

Conclusions

An osteotomy of the premaxilla in combination with secondary alveolar bone grafting appears to be the most successful technique. Combining early secondary alveolar bone grafting with osteotomy creates more room to ensure a watertight closure of the nasal mucosa resulting in fewer postoperative complications. Before surgery, the orthodontist should try to optimise the position of the premaxilla for its surgical correction prior to bone grafting.

Clinical relevance

The treatment of BCLP patients is still based on experience and expert opinions. This literature analysis tries to give a summery on how to handle the protruded and displaced premaxilla.

Predictive factors for premature loss of Martin 2.7 mandibular reconstruction plates

Mandibular reconstruction with a plate, with or without a vascularised free (bone) flap, is commonly used to treat patients with a segmental mandibular defect. Common complications are loosening of the osteosynthesis screws, malposition, intraoral or extraoral exposure, or infection. To define prognostic factors for premature loss of such plates and improve future planning, we designed a retrospective study of all patients operated on between 2005 and 2011 for reconstruction of a mandibular segmental defect with a reconstruction plate with or without a free vascularised (bone) flap. Prognostic factors collected from medical records were the patient's age, sex, and American Society of Anesthesiologists (ASA) grade; treatment with radiotherapy; whether they had diabetes or smoked; the site of the mandibular defect; whether there was a dental occlusion; the number of screws used on each side, and the use of a free vascularised (bone) flap; and whether the diagnosis was of oral cancer, benign tumour, or trauma. One hundred patients were included, 79 with oral cancer, 19 with benign tumours, and 2 with trauma. In 20 patients the Martin 2.7 reconstruction plate failed. Diabetes and smoking were significant prognostic factors for premature loss of the reconstruction plate with a hazard ratio of 2.95 (95% CI 1.068-8.172), p value=0.04, for diabetes, and 2.42 (95% CI 1.006-5.824), p value=0.05, for smoking. Smokers and diabetic patients have a higher risk of failure after mandibular reconstruction with a 2.7 reconstruction plate.

Long-term effect of a nurse-led psychosocial intervention on health-related quality of life in patients with head and neck cancer: a randomised controlled trial

BACKGROUND

Head and neck cancer (HNC) patients are prone to have a poor health-related quality of life after cancer treatment. This study investigated the effect of the nurse counselling and after intervention (NUCAI) on the health-related quality of life and depressive symptoms of HNC patients between 12 and 24 months after cancer treatment.

METHODS

Two hundred and five HNC patients were randomly allocated to NUCAI (N=103) or usual care (N=102). The 12-month nurse-led NUCAI is problem-focused and patient-driven and aims to help HNC patients manage with the physical, psychological and social consequences of their disease and its treatment. Health-related quality of life was evaluated with the EORTC QLQ-C30 and QLQ H&N35. Depressive symptoms were evaluated with the CES-D.

RESULTS

At 12 months the intervention group showed a significant (P<0.05) improvement in emotional and physical functioning, pain, swallowing, social contact, mouth opening and depressive symptoms. At 18 months, global quality of life, role and emotional functioning, pain, swallowing, mouth opening and depressive symptoms were significantly better in the intervention group than in the control group, and at 24 months emotional functioning and fatigue were significantly better in the intervention group.

CONCLUSION

The NUCAI effectively improved several domains of health-related quality of life and depressive symptoms in HNC patients and would seem a promising intervention for implementation in daily clinical practice.

A lower border augmentation technique to allow implant placement after a bilateral mandibular fracture as a complication of vertical distraction osteogenesis: a case report

As with other techniques, vertical distraction osteogenesis (VDO) can also induce complications. The case of a patient with a residual alveolar ridge in the symphyseal area of 8 mm is presented. After performing VDO, the patient returned at 1-day postoperatively complaining of pain and dislocation of the distractor device, due to a fracture of the lower mandibular segment on the right side. After removal of the distractor device and application of osteosynthesis plates, the patient returned 2 weeks later due to a second fracture of the lower segment, yet on the left side. After removing the osteosynthesis material, stabilization of the mandible was achieved with an acrylic splint, which was fixated with peri-mandibular wiring. Finally, reconstruction was accomplished by lower border onlay grafting, limited to the symphyseal area, in preparation for implant insertion. Ultimately, after a healing period of 5 months, two endosseous implants were installed. The patient's function has remained satisfactory for 3 years. Reinforcement of the extreme resorbed edentulous mandible after fracture healing by lower border bone augmentation can be a reliable method to allow implant installation in a second stage.

A gene expression profile for non-smoking and non-drinking patients with head and neck cancer

OBJECTIVE

A small subset of patients with head and neck squamous cell carcinoma are non-smoking and non-drinking and have distinct clinical characteristics. We aimed to identify a possible different genetic profile for these patients when compared with their smoking and drinking counterparts.

MATERIALS AND METHODS

The gene expression data previously detected from primary tumors located in the oral cavity and oropharynx, using DNA microarray was analyzed for their differential expression between non-smoking and non-drinking patients (n = 15) and smoking and drinking patients (n = 89). Student's T-test (P < 0.05) and 10-fold cross-validation procedure (100 times repeated) were performed to determine differentially expressed genes.

RESULTS

Non-smoking and non-drinking patients were older, mostly female and had oral cavity-localized tumors, whereas smoking and drinking patients were younger male patients with 81% oral cavity and 19% oropharynx tumors. A set of 49 differentially expressed genes were detected. Among others, seven genes related to interferon-γ were upregulated and two genes linked to NFKB pathway were downregulated.

CONCLUSIONS

Differentially expressed genes in non-smoking and non-drinking patients possibly indicate the presence of a different cellular response to carcinogenic events in these patients. Further studies are warranted to validate this gene set and explore possible therapeutic implications to improve prognosis for these patients.

The influence of a Le Fort I impaction and advancement osteotomy on smile using a modified alar cinch suture and V-Y closure: a prospective study

A previous report from the authors' department showed that a modified alar cinch suture combined with a muco-musculo-periosteal V-Y closure (mACVY) improves nasolabial mobility. To test if the improvements were equal to the range of nasolabial mobility in non-dysgnathic persons, a prospective study was carried out in 56 patients: 31 with mACVY, 25 with simple closing sutures (SCS) and 18 non-operated, angle class I volunteers. Standardized full facial frontal photographs, taken immediately preoperatively and 18 months postoperatively were used. The landmarks, alare, crista philtri and cheilion were analysed. The test has a standard deviation of 0.9 mm. Intra-group changes, paired t-test, and inter-group differences, unpaired t-test (p<0.05) were statistically analysed. The results show significant preoperative differences in nasolabial mobility compared with the control group, for both groups. Postoperative mobility improved in both groups, but significantly with mACVY with horizontal movement of cheilion and alare, and the vertical movement of crista philtri and less so for the vertical movement of crista philtri with SCS. Postoperative inter-group differences in mobility were small and significant for SCS vs the control group. It can be concluded that using mACVY improves orofacial movement to the level of normal class I volunteers.

Tongue function in patients treated for malignancies in tongue and/or floor of mouth; a one year prospective study

Progress in (reconstructive) surgery and radiotherapy tends to improve survival and reduce oral functional deficits. Despite the growing sophistication of cancer treatment, patients still report deterioration in tongue function. Sensory function, mobility, and force of the tongue were determined in 45 patients with a carcinoma of tongue and/or floor of mouth. Measurements were performed before surgery, shortly after surgery, shortly after radiotherapy, 6, and 12 months after surgery. Surgery had a negative impact on tongue sensory function and mobility. Post-surgery radiotherapy did not further deteriorate sensory function, mobility, or force of the tongue. Patients in the surgery-radiotherapy group (SRG) had significantly worse tongue sensory function and mobility than patients in the surgery group (SG), probably caused by more advanced tumour stage and more extensive reconstructions and related scar tissue. The tongue force in patients in both groups significantly increased in the first 6 months after surgery, but this increase disappeared in the next 6 months. The authors conclude that surgery had a significant negative influence on tongue function, especially in the group of patients treated with radiotherapy. No further deterioration of tongue function was observed after post-surgical radiotherapy within the first year after surgery.

Extra-oral implants: insertion per- or post-ablation?

Although the benefit of extra-oral implants in the reconstruction of maxillofacial oncological defects is undisputable, some relevant issues need to be clarified. The purpose of this retrospective study was to evaluate the relationship between implants placed during ablation (DA-implants) and after ablation (AA-implants) of the tumor with respect to implant survival. In total, 103 implants were assessed: 44 nasal implants (17 patients) and 59 orbital implants (18 patients). All patients received their implant-retained maxillofacial epithesis between 1997 and 2010, with a mean follow-up of 35 months (range 8-156 months). The survival rate of DA-implants was 90.0% for the orbital region and 93.5% for the nasal region. The survival rate of the AA-implants for the orbital and the nasal region was 82.8% and 61.5%, respectively. This study shows a significant higher survival rate of extra-oral implants placed during ablative surgery compared to implants in a later stage (p=0.044), thereby stressing the importance of installing extra-oral implants during the ablative surgical session.

Human Papillomavirus and Oropharyngeal Squamous Cell Carcinoma: A Case-Control Study regarding Tobacco and Alcohol Consumption

We aimed to determine the role of HPV in the pathogenesis and outcome of oropharyngeal squamous cell carcinoma (OSCC) in lifelong nonsmoking and nondrinking patients. A case-case analysis was performed to compare the presence of HPV-DNA in tumor cells of 16 nonsmoking and nondrinking with 16 matched smoking and drinking patients (matching criteria: age at incidence, gender, tumor sublocation, tumor stage). HPV was detected using 2 PCR tests, FISH analysis, and p16^INK4A immunostaining. Nonsmoking and nondrinking patients had more HPV-positive tumors than smoking and drinking patients (n = 12; 75% versus n = 2; 13%; P < 0.001). All HPV-positive tumors showed p16^INK4A overexpression, and 1 HPV-negative tumor had p16^INK4A overexpression, (P < 0.001). Overall survival and disease-specific survival were higher for HPV-positive compared to HPV-negative cases (P = 0.027, P = 0.039, resp.). In conclusion, HPV is strongly associated with OSCC of nonsmoking and nondrinking patients. Specific diagnostic and therapeutic actions should be considered for these patients to achieve a better prognosis.

[Diagnosis and classification of headache and temporomandibular disorders, a new opportunity]

Patients with orofacial pains are generally treated by physicians. A small number of patients are treated for pain in the temporomandibular joint, the masticatory and the neck muscles, by dentists and orofacial surgeons. Among half of the patients being treated in neurological headache clinics, the temporomandibular joint and the masticatory muscles are the source of the pain. In order to achieve better research and a classification, the International Headache Society, consisting largely of neurologists, developed a classification system. A comparable development occurred among oral health specialists. Employing these 2 methods with the same patients leads to different diagnoses and treatments. Both the International Classification of Headache Disorders II and the Research Diagnostic Criteria for Temporomandibular Disorders are being revised. This creates the opportunity to establish a single classification for these orofacial pains, preferably within the new International Classification of Headache Disorders.

[An emergency tracheotomy in case of airway compromise after post-operative bleeding associated with the use of an antidepressant]

Selective serotonin reuptake inhibitors block the uptake ofserotonin into thrombocytes. One of the functions of serotonin in thrombocytes is to promote platelet aggregation. When serotonin levels are depleted after several weeks of treatment, the altered platelet function leads to increased risk of abnormal bleeding. In patients taking a combination of a selective serotonin reuptake inhibitor and a non-steroidal anti-inflammatory drug, the risk ofabnormal bleeding is thought to be even higher. A case is reported of abnormal bleeding after treatment in the oral cavity, associated with simultaneous use of a selective serotonin reuptake inhibitor and a non-steroidal anti-inflammatory drug. A large haematoma in the floor of mouth caused airway compromise which necessitated an emergency tracheotomy. Until greater insight is achieved by means of additional research, increased attentiveness for these patients seems to be called for and extra care should be employed. Additional haemostatic measures could be considered.

The effect of alar cinch sutures and V-Y closure on soft tissue dynamics after Le Fort I intrusion osteotomies

Adverse effects on the soft tissues after Le Fort I osteotomies include: broadening of the alar base, loss of vermilion show of the upper lip and down sloping of the commissures. In theory, an alar cinch suture combined with a muco-musculo-periosteal V-Y closure (ACVY) should improve not only the nasal width, but would also improve the dynamics of some of the mimic muscles. To test the validity of this hypothesis, a prospective study was set up including 22 patients, using standardized full facial frontal photographs, taken immediately preoperatively and 18 months postoperatively. Sets containing three pictures were made: soft tissue in repose, maximum closed mouth smile and maximum smile. The landmarks, alare, crista philtri and cheilion were analysed. The preliminary results show that ACVY-closure does significantly improve the horizontal movement of cheilion with both maximum closed mouth smile and maximum smile, as well as the vertical movement of crista philtri with maximum closed mouth smile.

CONCLUSION

The Le Fort I osteotomy with ACVY improves the orofacial dynamics.

The prediction of mandibular invasion by squamous cell carcinomas with the expression of osteoclast-related cytokines in biopsy specimens

Destruction of bone by tumour is caused by osteoclasts rather than by tumour cells directly. Tumour cells of invasive oral squamous cell carcinomas (SCC) release osteoclast-related cytokines and cytokines activate osteoclasts. The purpose of this study was to investigate the possibility of predicting mandibular invasion by SCC by analysis of the expression of osteoclast-related cytokines in biopsy specimens of SCC, adjacent or fixed to the mandible. Thirty-five biopsy specimens from the pathology archives were examined from patients who had been treated for SCC, adjacent or fixed to the mandible. The patients were divided into those with and without medullary invasion. The expression of tumour necrosis factor (TNF)-alpha, interleukin (IL)-6 and IL-11 was studied by immunohistochemical analysis. No significant differences were found in expression of TNF-alpha, IL-6 and IL-11 between biopsy specimens with or without medullary invasion. Quantification of the density of tumour-infiltrating lymphocytes was not reproducible. In conclusion, the expression of TNF-alpha, IL-6 and IL-11 in biopsy specimens of SCC, adjacent or fixed to the mandible, is not an appropriate method for predicting the presence of medullary invasion of the mandible.

Complications in alveolar distraction osteogenesis of the atrophic mandible

To improve the starting point for placement of dental implants, 45 patients suffering from atrophied edentulous mandibles, with a vertical height varying between 7.3 and 15.8mm, were treated by alveolar vertical distraction osteogenesis (VDO). The mean follow-up period was 3 years, ranging from 1 to 7 years. Associated complications, as occurred during instalment of the distractor device, VDO period and consolidation phase, and also after dental implant placement, were evaluated. Observed complications were: early fractures (2%), late fractures (17%), bleeding or haematoma (4%), infections (6%), skin perforation (2%), mucosal dehiscence (8%), sensory disturbances (28%), sagging chin (13%) and failure of dental implants (13%). In 10 patients 2 complications and in 1 patient 3 complications were monitored. All complications occurred in the first year. It is concluded that VDO to restore vertical bone height in patients with mandibular atrophy is a surgically delicate technique with a high risk of various complications. The likelihood of the most striking complication, namely fracture occurrence, increases with decreasing residual bone height.

[Bisphosphonate-associated osteonecrosis of the jaws. 2. Six case reports]

The diagnostic procedures and the treatment of 6 patients with bisphosphonate-related osteonecrosis of the jaw are reported. During recent years, bisphosphonates have been prescribed with increasing frequency. The main pharmacological effect is the inhibition of bone resorption, mediated by osteoclast activity impairment. The osteonecrosis is usually very therapy resistant and may cause considerable morbidity. Therefore, oral screening is indicated and focal oral infections should be eradicated prior to therapy with bisphosphonates. If bisphosphonate therapy has already been started, invasive oral procedures should be restricted to unavoidable treatment. When invasive treatment can not be avoided, the risk of osteonecrosis may be reduced by primary wound closure, antibiotic prophylaxis and adequate oral hygiene measures, supplemented by using a chlorhexidine mouthrinse. Cessation of smoking is recommended.

[Absence of (jaw)bone may be indicative of malignancy]

Following the loss of several molars in the left maxilla, a 73-year-old man asked his general dentist practitioner to restore his chewing efficiency. Initially, reconstruction of the left maxilla with an implant supported fixed partial denture was considered. However, intraorally a soft-tissue swelling was observed extending from the midline of the palate to the left buccal sulcus. A panoramic radiograph showed absence of bone between the oral cavity and the maxillary sinus. At first, after an incision biopsy and histopathologic examination, the condition was diagnosed as nodular fasciitis. However, because of subsequent aggressive growth of the lesion malignancy was suspected. Histopathological examination confirmed the assumption. The lesion appeared to be a sarcoma. The general diagnostic rule is that the aggressive behaviour of a lesion and the absence of a bony delineation on radiographic examination between the oral cavity and the maxillary sinus are signs of malignancy, until evidence to the contrary has been provided.

[Recovery of oral function following surgical treatment for an oral cavity cancer]

Ablative surgery for oral cancer results in loss or alterations of anatomical structures, which may impair oral functions, such as speech, mastication, and swallowing. Oral functions are impaired further by significant side-effects of additional postoperative radiation therapy. Improvement of oral functions may be achieved by implant-supported prosthetic rehabilitation. The recommended treatment is a 4-implants retained overdenture. A fixed 2 unit implant-supported partial denture seems a feasible alternative treatment.

The reliability of frontal facial photographs to assess changes in nasolabial soft tissues

A simple, modified method to evaluate changes in the nasolabial soft tissues after orthognathic surgery is presented. Eighteen healthy volunteers were photographed in a standardized manner with a 2-month interval. Pictures were taken with the soft tissues in repose and 'maximum closed mouth smile'. Discrepancies for repose and dynamic excursions (x and y coordinates) were calculated for the landmarks alare, crista philtri and cheilion. Multiple analysis of variance revealed no significant interaction for intra-observer variance and time of recording. Coefficients of reliability (repose: 90-99%, dynamic excursion (cheilion): >95%), Spearman correlation coefficients (repose: >0.8, dynamic: >0.6) and squared correlation (repose: >75%, dynamic: >50%) showed this method to be reliable for repose and dynamic excursions. The error of measurement was less than 1.8 mm for both repose and dynamic excursions (SD(differences)=0.9 mm). This is smaller than mean differences in nasolabial soft-tissues excursions found between the pre- and post-Le Fort I osteotomy situation in a previous study using video imaging. The discrepancies found were in keeping with other earlier reports for 2D and 3D measuring methods. The method as proposed is simple, cost effective and can be used to evaluate soft-tissue changes after orthognathic surgery.

[Arteriovenous malformation in the mandibula]

A 15-year-old autistic boy of subnormal intelligence appeared at the office of his dental practitioner complaining about pain in the third quadrant. Investigation revealed that the second molar could be intruded easily. No other irregularities, such as caries or periodontal disease were apparent. Due to the severe pain it was decided that the tooth should be extracted. Extraction of the tooth induced massive bleeding. Hemostasis was achieved by repositioning the molar in its alveolus, according to the principle of putting a cork in a bottle. Radiographic investigation showed the presence of an intraosseous arteriovenous malformation. These malformations are potentially life-threatening lesions. Treatment of choice is a combination of transarterial embolization and surgical removal of the malformation.

Fixed partial dentures on two implants: raising comfort in irradiated edentulous patients

Surgical treatment of malignancies involving the oral cavity often results in an altered anatomical situation, which may severely hamper oral function. Postoperative radiotherapy resulting in reduced salivary secretion further worsens functions such as speech, chewing (mastication) and swallowing. In order to improve oral functioning, the use of dental implants was proposed. To reconstruct the edentulous mandible, especially in cases involving postoperative irradiation, implant-borne prosthetic construction on four permucosal implants has been advocated, but this treatment concept has some practical drawbacks. As the chewing force is reduced as a result of irradiation of the masticatory muscles, it is hypothesized that a fixed prosthetic construction on only two implants is a feasible alternative. Up until now 10 patients have been treated successfully according to this concept at the authors' clinic.

Professional delay in head and neck cancer patients: Analysis of the diagnostic pathway

The aim of this study was to identify which factors are related to specialist delay and to determine the length of the diagnostic pathway in head and neck cancer patients. Three hundred and six patients with a carcinoma of the larynx, pharynx or oral cavity were included in the study. Logistic regression analysis was used to identify risk factors for specialist delay. Large (T3-T4) tumors showed significantly less specialist delay than small (T1-T2) tumors (p=0.045, odds ratio [OR]=0.6). Pharyngeal (p=0.00, OR=0.2) and oral carcinomas (p=0.00, OR=0.2) had less specialist delay than glottic carcinomas. Hoarseness was associated with prolonged specialist delay (p=0.00, OR=5.9). Heavy drinking in combination with smoking (p=0.005, OR=0.3), a sore throat (p=0.02, OR=0.4) or having a lesion (p=0.03, OR=0.2) showed a shorter diagnostic period. The duration of the diagnostic process in a general hospital ranged from 0 to 570 days, with a median of 14 days. Only a small group of patients met the ideal management standards in our head and neck clinic. Although prolonged delay was associated with small (glottic) tumors, the diagnostic process takes a fairly long time. The results indicate that continued educational programs for professionals are warranted.

Testing of iatrogenic lingual nerve injury using a novel psychophysical method and oral reflexes

In a case of long-term sensory loss in the tongue following third molar extraction, a novel, efficient and effective psychophysical test was used. This initial test, which includes the presentation of pairs of a real and fake stimulus, and a forced-choice response, was applied to determine whether relatively thick or thin afferent fibres of the lingual nerve were affected. The results suggested that thick fibres on the right tongue side were mainly affected. Sensory loss was confirmed and its extent assessed by a standard test determining thresholds of light touch. Furthermore, sensory function was determined by an objective test based on inhibitory reflexes in masseteric electromyographic activity following electrical stimulation of oral tissue. Reflex features that are important for within-patient diagnosis are a difference between the injured and control sides in latency of the first reflex, and also in depth-contrast in signal amplitude between both sides at the post-stimulus time of the trough of an inhibition on the uninjured side. In agreement with the findings from the psychophysical tests, the finding of the absence of an early component of both inhibitions suggested sensory loss related to dysfunction of fast-conducting, relatively thick afferent fibres of the lingual nerve. Apart from being used for medicolegal reasons, the objective reflex test may have conclusive prognostic value or may influence surgical therapeutic decisions.

Non-smoking and non-drinking patients with head and neck squamous cell carcinoma: a distinct population

OBJECTIVE

To recognize specific clinicopathological characteristics of non-smoking and non-drinking (NSND) head and neck squamous cell carcinoma (HNSCC) patients. This can increase our knowledge regarding a potentially different carcinogenesis in these patients.

STUDY DESIGN/METHODS

Retrospective analysis of data for 195 NSND patients with HNSCC and comparison with data for patients with HNSCC obtained from the Netherlands Cancer Registry.

RESULTS

Compared with all HNSCC patients in the Netherlands, our NSND patients with HNSCC were typically female (n = 142; 73%vs 26%), old at disease presentation (mean 73 years vs 64 years), and had tumors mainly of the oral cavity (n = 130; 66%vs 25%). Most tumors were stage I (n = 67; 34%) and stage IVA (n = 59; 30%). The incidence of second primary tumors (SPTs) was high (n = 32; 16%), mainly occurring in the oral cavity (n = 26; 13%).

DISCUSSION/CONCLUSION

Our study confirms that NSND HNSCC patients have different clinicopathological characteristics from those of the overall HNSCC population; however, the frequency of SPTs is as high in NSND patients as in patients who smoke and drink alcohol. More research, and particularly molecular data are needed to obtain a better understanding of head and neck cancer in NSND patients.

[An unusual skin disorder after tooth extraction]

A 72-year-old woman was referred to a department of oral and maxillofacial surgery because of a unilateral skin eruption of the face after extraction of the right first upper molar, a few days earlier. She had been diagnosed with chronic lymphocytic leukaemia some years before. It appeared to be herpes zoster or'shingles'from the second branch of the trigeminal nerve. Treatment included hospital admission with intravenous antiviral therapy and analgetics. Herpes zoster of the face is a severe infection and requires early treatment. Post herpetic neuralgia is a serious complication of herpes zoster and may adversely affect the quality of life.

Functional results after conservative treatment of fractures of the mandibular condyle

Since the introduction of osteosynthesis materials for rigid internal fixation after anatomical reduction there is an ongoing discussion about the treatment of condylar fractures of the mandible. Sixty patient files were analyzed and 28 patients were seen for re-examination and a x-orthopantomogram was taken. Functionality was graded with the Helkimo index at an average of 3.0 years follow-up. The clinical dysfunction index showed: severe symptoms in 11%, moderate symptoms in 39%, mild symptoms in 39% and 11% had no symptoms. Index for occlusal state showed: 21% severe occusal disturbances, 61% moderate occlusal disturbances and 18% no occlusal disturbances. According to the anamnestic dysfunction index 89% of the patients were symptom-free. The clinical outcome group showed a significant left/right ramus length difference compared with a 20-person control group. The re-examined group did not significantly differ from the control group. Conservative treatment for condylar fractures was successful in only 46% according to the 1999 consensus criteria described by Bos et al.

Guidelines in head and neck oncology compliance and consequences of deviations from the standard protocol for tongue and floor of mouth squamous carcinoma

OBJECTIVES

To investigate the extent of violation of a regional guideline for the treatment of patients with carcinoma of the tongue/floor of mouth (ICD0 C02, C04). Different aspects of protocol violation (i.e. undertreatment or overtreatment) and consequences for treatment outcome were evaluated.

DESIGN

Retrospective analysis of data from medical records.

SETTING

The Department of Maxillofacial and Oral Surgery and the Department of Otorhinolaryngology and Head and Neck Surgery of the University Medical Centre Utrecht.

PARTICIPANTS

A total of 217 patients treated between 1991 and 2001 for a stage II and stage III carcinoma of the tongue/floor of mouth.

MAIN OUTCOME MEASURES

Protocol violation, tumour recurrence.

RESULTS

The overall adherence to the guideline was 55%. In the non-adherence group of patients, 21% were overtreated, 71% were undertreated, and 8% were both overtreated and undertreated. There was no statistically significant difference in tumour recurrence between the two groups for stage II (P=0.68) or stage III (P=0.97) disease, or between undertreatment and overtreatment of patients with stage II (P=0.47) or stage III (P=0.90) disease.

CONCLUSIONS

Although protocol violation occurs in as many as 45% of patients, this does not result in a worse tumour recurrence. Neither overtreatment nor undertreatment appears to affect the overall tumour recurrence.

The influence of orthognathic surgery on masticatory performance in retrognathic patients

Surgical correction of retrognathism may influence chewing performance and its underlying mechanisms selection and breakage of food particles. In this study we examined the hypothesis that treatment of this anomaly improves chewing performance. Furthermore, we determined to what extent this change can be attributed to selection and breakage of food particles. Eleven patients were tested before and 1-1.5 years after surgery. To determine chewing performance, eight cubes of 8 mm of a silicone rubber (Optosil) were used as a test food. Selection and breakage were determined in one-chew experiments using three particle sizes. On average, no differences were found for chewing performance, selection or breakage. However, on an individual basis, patients with a poor chewing performance before surgery tended to improve, whereas no improvement was observed for patients with a good chewing performance. The change in chewing performance was mainly due to a change in breakage of the food particles.

Anterior tooth replacement with implants in grafted alveolar cleft sites: a case series

When a residual edentulous space in the anterior region remains after surgical and orthodontic treatment of alveolar cleft patients, implant placement with or without additional grafting is a treatment option. We placed a total of 10 implants in nine consecutive alveolar cleft patients (five females, four males) with residual anterior edentulous spaces and non-restored neighbouring teeth. Patient age generally varied from 18 to 22 years. Additional (tertiary) bone grafting, implant placement after 3 months of graft consolidation and implant uncover after no less than 6 months was the favoured surgical protocol in the five most recent cases. Ample time was allowed to evaluate and guide the development of soft tissues, following second-stage surgery. For this purpose, temporary crowns were fabricated, adjusted and left in place for over 3-4 months in seven out of nine cases. No implants were lost after a mean observation period of 3.4 years and all implants function without objective (radiographic) or subjective problems. Aesthetics were considered acceptable in seven out of nine cases. Unsatisfactory aesthetic results originated from poor implant positioning or alignment in two patients who did not undergo tertiary bone grafting. We conclude that implant placement in alveolar cleft sites is a comprehensive but viable treatment option. Tertiary grafting of the site is recommended to achieve better ridge contour and bone height. This allows optimal implant placement and alignment.

[Complications during and after dentoalveolar surgery]

In dentistry complications are undesirable adventures provoked by oral health care delivery. If there is any risk of a complication, the patient needs to be informed before treatment. Occurrence of complications can be minimized by adequate diagnostics and planning sufficient time for treatment. The most common complications during and after dentoalveolar surgery are discussed, such as complications during or after producing local anaesthesia, nerve injuries, complications during or after tooth extraction, aspiration, jaw luxation, disturbed wound healing, and complications during or after implantation procedures.

[Oral surgery in hemophilia patients]

Oral surgery in hemophilia patients requires special arrangements in close collaboration with a hemotologist. Minor oral surgeries in not complicated cases can be done by a dentist or an oral surgeon with aid and assistance of a hemotologist. All major oral surgeries in hemophilia patients with antibodies counteracting coagulation agents should occur in a hemophilia treatment centre.