The parameters of care for cleft lip and palate patients in Aarhus, Denmark

Aarhus Cleft Palate Institute receives approximately 75 new cleft patients a year. Due to statuary notification of all newborn cleft patients to the Institute, the treatment protocol can be offered to the family from right after birth, and a coordinated team approach can be established. The individually planned primary surgery, speech and growth of the maxillo-facial skeleton is followed by regular team examinations. Speech development is followed from the child is one year old in order to be able to provide speech assessment as soon as problems of hypernasality and articulation disorders or language delay is evident. One of the goals of speech assessment is to achieve acceptable speech as early as possible and at best before school start. Orthodontic treatment is usually started at 8 years of age, in UCLP and BCLP patients in combination with bonegrafting at 9-11 years of age. In patients with impaired growth of the maxilla, attention is paid to identify candidates for orthognathic surgical treatment as early as possible. All secondary surgical treatment on jaws, lips and nose are coordinated and usually the treatment can be finished by the late teens. The described team approach towards the parameters of care for cleft lip and palate patients has basically been used for more than 50 years. A systematic follow-up and data collection on all patients provide a scientific base for evaluation of treatment results. Based on long-term investigations the protocol has gradually been modified during time to improve the quality of patient care.

A novel approach to bite force measurements in a porcine model in vivo

A novel device for a bite force measurement system in a porcine model is described. A single polyethylene layer was vacuum-formed into a splint, and a force sensor was fitted on to the splint occlusal surface and seated with a silicone layer. This design enabled the measurement of bite forces on selected teeth in a large animal model with either natural dentition or single implant crowns and could be used in assessing information on biomechanical adaptation of the bone-implant interface to masticatory loads. Preliminary recordings of force values obtained during mastication in the premolar region (200-560 N) and various limiting factors of the technical design are discussed.

Onset of acetaminophen analgesia: comparison of oral and intravenous routes after third molar surgery

BACKGROUND

The purpose of this randomized double-blind study was to compare the efficacy and safety of propacetamol 2 g (an i.v. acetaminophen 1 g formulation) administered as a 2-min bolus injection (n=50) or a 15-min infusion (n=50) with oral acetaminophen 1 g (n=50) or placebo (n=25) for analgesia after third molar surgery in patients with moderate to severe pain after impacted third molar removal.

METHODS

All patients were evaluated for efficacy during the initial 6 h period after treatment administration (T(0)) and for safety during the entire week after T(0).

RESULTS

The onset of analgesia after propacetamol was shorter (3 min for bolus administration, 5 min for 15-min infusion) than after oral acetaminophen (11 min). Active treatments were significantly better for all parameters (pain relief, pain intensity, patient's global evaluation, duration of analgesia) than placebo (P<0.05). Adverse events were more frequent after propacetamol, especially pain at the injection site. Propacetamol bolus resulted in a much higher incidence of local adverse events than the infusion (propacetamol bolus 90% vs propacetamol infusion 52%) with no clinically significant benefits in terms of analgesic efficacy.

CONCLUSION

I.V. propacetamol, administered as a 15-min infusion, is a fast-acting analgesic agent. It is more effective in terms of onset of analgesia than a similar dose of oral acetaminophen.

Advances in surgical dentistry

The introduction of the specialty of surgical dentistry is an advance in itself and has far-reaching implications for the future. Surgical specialists will have a significant impact on the provision and resources of surgical dental services. This paper explores recent developments within the field.

Clinical and histological findings in guided bone regeneration (GBR) around titanium dental implants with autogeneous bone chips using a new resorbable membrane

The aim of this study was to test the value of a polydioxanon-membrane (PDS(R), Ethicon, Norderstedt, Germany) in combination with autogenous bone as a spacer for guided bone regeneration of denuded implant surfaces in comparison to simple augmentation. Altogether, in 8 Beagle dogs of 12 months, the three mandibular premolars were extracted on both sides and, after an uneventful healing of the extraction sockets in each mandibular site, two seize defined bone defects were produced. The defects were 7 mm long, had a vertical extension of 7 mm, and were 7 mm deep. These also included, therefore, the resection of the lingual cortical bone wall. In the center of all these 32 bone defects, Brânemark fixtures with a diameter of 3 mm and a length of 10 mm were implanted. Every implant was primarily stable due to the fixation in the native bone under the created defects. In each mandible site, one bone defect was filled with autologous bone resulting from the previous defect preparation. Half of the defects were covered with a PDS membrane, and the other half were covered only by the relocation of the mucoperiosteal flap. During the observation period of 90-180 days, continuous clinical and radiological controls were executed. Aside from the observed clinical healing problems in the test sites, such as exposure of the membranes and serious inflammatory reactions, the histological and radiological results of the control group regarding bone regeneration were superior to these of the test group, which were valid also for the subgroups with or without autologous bone fillings.

Time to onset of analgesia and analgesic efficacy of effervescent acetaminophen 1000 mg compared to tablet acetaminophen 1000 mg in postoperative dental pain: a single-dose, double-blind, randomized, placebo-controlled study

This randomized, double-blind, placebo-controlled study compared the time to onset of analgesia and the analgesic efficacy of two formulations of acetaminophen 1000 mg--an effervescent solution and tablet--in 242 patients with moderate or severe pain following dental surgery. Onset of analgesia was determined using a two-stopwatch procedure. Analgesia was assessed over a 4-hour period. Treatments were compared using standard indexes of pain intensity and pain relief and summary measures. Both acetaminophen formulations were significantly more effective than their corresponding placebo for all efficacy assessments. The median time to onset of analgesia was significantly shorter with effervescent acetaminophen (20 minutes) compared to tablet acetaminophen (45 minutes). During the first 45 minutes after administration, effervescent acetaminophen was significantly more effective at each scheduled assessment time than tablet acetaminophen. The median time to meaningful pain relief was significantly shorter with effervescent acetaminophen (45 minutes) compared to tablet acetaminophen (60 minutes). At 4 hours after administration, the pain relief was significantly better with tablet acetaminophen than with effervescent acetaminophen. No other significant differences were observed between the active treatments. In conclusion, effervescent acetaminophen produces a significantly faster onset of analgesia than tablet acetaminophen.

Outcome of treatment with implant-retained dental prostheses in patients with Sjögren syndrome

The purpose of this investigation was to evaluate the outcome of treatment with implant-retained prostheses in patients suffering from Sjögren syndrome. Eight women were included in the study; all had suffered oral symptoms of Sjögren syndrome for many years. Seven patients were edentulous in both arches, and 1 patient was edentulous in the maxilla only. All patients reported poor or very poor comfort levels with their conventional dentures. It was the intention to treat each arch that showed subjective and objective denture problems with a complete fixed prosthesis after placement of 6 implants. In all, 54 Brånemark dental implants were placed in these patients. No implants were lost, but 7 implants in 4 patients were clinically not osseointegrated at the time of the abutment connection procedure. Because of nonosseointegrated implants and lack of jawbone, 3 arches were treated with an implant-retained overdenture. Fixed prostheses were made with a titanium framework of premachined components welded together (Procera) and acrylic resin teeth and flanges. Patients answered a questionnaire regarding their oral function before the onset of treatment and 1 month and 2 years after treatment. An average radiographic bone loss of 0.7 mm from the time of implant placement to 1 year after treatment was observed; additional bone loss of less than 0.6 mm was recorded 4 years after treatment. During the first year of function 2 implants lost osseointegration. No prostheses were lost or remade. Treatment with implant-retained prostheses considerably increased the prosthetic comfort and function of the patients. Two years after prosthetic treatment, only 1 patient indicated poor comfort of the prostheses, while the remaining patients reported good or very good comfort levels.

Dental findings in three siblings with Morquio's syndrome

Three siblings with Morquo's syndrome are described. Cultured fibroblasts from the youngest sibling demonstrated a total absence of N-acethylgalactosamine-6-sulphate-sulphatase whereas beta-galactocidase activity was normal, thus verifying the diagnosis of MPS-IV A. Dental features such as pointed cusps, spade-shaped incisors, thin enamel and pitted buccal surfaces were observed in all three children. Furthermore, in all three siblings the TMJ was affected with severe resorption of the head of the condyle. Histological examination of exfoliated primary molars showed a band of increased porosity following the striae of Retzius in the outer part of the enamel. These developmental disturbances were occasionally associated with minor localized defects in the enamel surface. The importance of close monitoring of dental development and regular dental care in order to prevent attrition of the teeth, loss of vertical face height and subsequent risk of TMJ dysfunction is emphasized.

Tirilazad inhibits surgically induced edema and interleukin-1 production. An experimental study in rats

The aim of this study was to evaluate the anti-inflammatory effect of tirilazad mesylate on edema and interleukin-1 (IL-1) levels in serum following standardized surgical procedures. Four groups, each containing eight rats, were randomized for treatment as follows: A) no medication, B) low-dose tirilazad, C) high-dose tirilazad, and D) corticosteroids. The animals were examined by nuclear magnetic resonance imaging (NMRI) 24 and 72 hours after surgery and the NMRI data were used in the determination of soft tissue edema. In addition, serum was obtained for analysis of IL-1 levels. Four other groups of animals were subjected to the same treatment regimen as groups A-D), respectively, and 24 hours after surgery the animals were killed, whereafter serum was obtained for analysis of IL-1 levels. The present study demonstrated that low-dose tirilazad significantly reduces soft tissue edema compared with all other treatment regimens 24 hours postoperatively. At 72 hours postoperatively significant reduction of soft tissue edema was achieved at low-dose tirilazad when compared to high-dose tirilazad and steroids. In addition, a significant suppression of the expression of IL-1 was observed at 24 and 72 hours when comparing low-dose tirilazad and the control group.

Evaluation of a new radiographic technique: outcome following removal of mandibular third molars

OBJECTIVE

To compare the effect on outcome of third molar removal of pre-operative radiographic assessment by two different techniques.

METHODS

Two hundred and sixty three patients were allocated prior to surgery to one of two diagnostic groups. One hundred and thirty-seven were examined by the Scanora and 126 by a panoramic plus three intra-oral radiographs. Ten oral surgeons recorded their operating time in minutes. Postoperative pain was recorded 4 h after the operation by the patients on a Visual Analog Scale (VAS). The following clinical parameters were recorded at the 1-week postoperative examination: alveolitis, bleeding, and swelling related to the operation area, and any other complications such as paresthesia, nausea and trismus.

RESULTS

There was no significant difference in operation time between the two groups of patients (t-test; P > 0.82) nor in the frequency of immediate postoperative pain (chi 2-test; P > 0.5). There were no statistically significant differences in pain score between patients who experienced pain in the two groups (P = 0.10). Sixty-four patients experienced one or more postoperative complications, but the differences between the two groups were not statistically significant (chi 2-test; P > 0.05). There were no significant differences between the surgeons in the number of patients they operated on who experienced pain (chi 2-test; P = 0.18) or who developed complications (chi 2-test; P = 0.27).

CONCLUSION

There are no adverse effects on the rate of postoperative complications when surgeons with little experience with it base their diagnosis and treatment plan on Scanora compared with conventional radiography.

Evaluation of a new radiographic technique: diagnostic accuracy for mandibular third molars

OBJECTIVE

To compare the accuracy of Scanora with that of traditional panoramic and intra-oral radiography for the assessment of impacted mandibular third molars.

METHODS

Two hundred and fifty-four patients referred for removal of impacted or partly erupted third molars were randomly allocated to one of two groups; 133 were examined by the Scanora system and 121 by a panoramic plus a series of three intra-oral radiographs. The radiographs were read by a trained oral radiologist and her diagnoses validated against the surgeons' findings at operation.

RESULTS

There was agreement about the state of tooth eruption in 71.4% of Scanora and 74.4% of conventional examinations and about tooth position in 77.2 and 69.7% respectively (P < 0.05). The number of roots was assessed more accurately by Scanora (82.7% agreement) than by conventional (71% agreement) examination (P < 0.05). There was agreement about the root morphology in 70.4% of Scanora and 62.4% of conventional examinations. In 12% of the patients, the roots were in very close contact with the canal determined by the surgeon. In approximately 50% of these cases, the close contact to the canal was found by radiography with no significant differences between the methods.

CONCLUSION

The Scanora method was more accurate when validated against the surgeons' findings for the position and number of roots of ectopic mandibular third molars while both methods were equally accurate in demonstrating the relation between the roots and the inferior alveolar nerve.

Growth and endocrinological disorders up to 21 years after treatment for acute lymphoblastic leukemia in childhood

BACKGROUND

Our aim was to evaluate endocrinological status 10-21 years after treatment for childhood acute lymphoblastic leukemia (ALL) with chemotherapy (C) and cranial irradiation (C + I) or only C, and to correlate the endocrine data with growth parameters.

PROCEDURE

Of 30 patients (15 females and 15 males), 18 were treated with C + I and 12 were treated with C only. Height standard deviation score (HSDS) and body mass index standard deviation score (BMISDS) before treatment, at end of treatment, and at follow-up were calculated from height and weight registered from the charts. At follow-up examinations, provocative growth hormone (GH) tests (clonidine and insulin tolerance test) and an ACTH test were performed. Furthermore, blood samples for hormonal analysis, IGF-I, IGFBP-3, GHBP, and leptin were drawn.

RESULTS

Eleven patients (9 treated with C + I and 2 treated with C) showed insufficient response to GH tests. Two patients had hypogonadism. HSDS and IGF-I were significantly lower and GHBP significantly higher in GH-deficient patients compared to the group with normal GH secretion at follow-up. BMISDS steadily increased from start of treatment until follow-up, independent of GH status at follow-up. BMISDS at follow-up was positively correlated with serum leptin (P < 0.001), and serum leptin was significantly higher in the cranial irradiated group as compared to the nonirradiated group.

CONCLUSIONS

GH deficiency is frequently found at long-term follow-up in patients treated for childhood ALL. Other hormonal deficiencies are rare. HSDS at long-term follow-up is dependent on GH secretory status. Long-term endocrinological follow-up examinations in patients treated for childhood ALL are recommended, as hormonal replacement therapy may be indicated.

In vitro analysis of the accuracy of subtraction radiography and computed tomography scanning for determination of bone graft volume

PURPOSE

This study evaluated the accuracy of digital subtraction radiography (DSR) and three-dimensional computed tomography (3D CT) for determination of bone graft volume in the maxillofacial region.

MATERIALS AND METHODS

Standardized bone defects were made on the top of the alveolar ridge in 10 dry pig mandibles. To resemble the clinical situation, a bone block was harvested from the symphyseal region of the mandible and fixed in the defect. True bone graft volume was determined by the water displacement technique (VOL I) and correlated to direct measurements by calipers (VOL II). The mean gray value of the bone graft as imaged by DSR was correlated to the directly measured thickness. Furthermore, VOL I was correlated to the 3D CT of the bone graft (VOL III) and to the 3D CT with the bone graft fixed in the defect (VOL IV).

RESULTS

There was a strong correlation between VOL I and VOL II (r = .95), whereas there was a poorer correlation between mean gray level in DSR and measured bone thickness (r = .63). A strong correlation was also registered between VOL I and VOL III (r = .97) and VOL I and VOL IV (r = .97).

Evaluation of trismus, bite force, and pressure algometry after third molar surgery: a placebo-controlled study of ibuprofen

PURPOSE

This study evaluated trismus, bite force, and pressure algometry as measures of analgesic efficacy after third molar removal.

PATIENTS AND METHODS

Fifty-seven patients (36 females and 21 males) developed at least moderate pain after surgical removal of a mandibular third molar and were given either ibuprofen, 400 mg (n = 26), or placebo (n = 31) in a double-blind study. Pain intensity and pain relief were rated on a five-point verbal rating scale during the 4-hour study period. Recordings of trismus, bilateral pressure pain detection and tolerance thresholds, and bite force were performed before surgery, at medication, and hourly for 4 hours. Changes in the functional variables were calculated as percent change from baseline (before surgery).

RESULTS

The pain intensity and pain relief ratings showed significant differences between the ibuprofen- and placebo-treated patients in the 4-hour study period. The changes in trismus, bite force, and pressure pain thresholds were in accordance with these pain ratings. Pressure pain detection threshold on the operated side was significantly lower in the placebo-treated patients compared with the ibuprofen-treated patients 2 and 3 hours after medication, whereas pressure tolerance threshold showed a significant difference after 2 hours. Bite force on the operated side was significantly less reduced 3 hours after treatment with ibuprofen when compared with placebo.

CONCLUSIONS

The functional measures used support the results obtained by rating of pain intensity and pain relief, and could be of value as measures of the efficacy of an analgesic to reduce functional impairment caused by postoperative pain.

Reconstruction of residual alveolar cleft defects with one-stage mandibular bone grafts and osseointegrated implants

PURPOSE

This study evaluates a treatment regimen for reconstruction of residual maxillary alveolar cleft defects consisting of mandibular bone grafting and immediate implant installation.

PATIENTS AND METHODS

Sixteen cleft patients (five female and 11 male) had residual cleft defects of the alveolar ridge reconstructed with bone grafts from the mandibular symphyseal region. The bone graft was pretapped at the donor site before fixation in the residual ridge with Brånemark implants. Twenty implants were installed according to this concept. The period of observation ranged from 36 to 69 months, with a mean of 48 months after implant installation.

RESULTS

Five patients developed wound dehiscenses that resulted in total or partial bone graft sequestration. Two implants were lost, one due to sequestration and the other due to mobility at the abutment procedure; 18 implants were still well functioning at the end of the observation period. However, all patients showed significant periimplant bone resorption after this one-stage treatment.

CONCLUSION

Because of the observed complication rate, the one-stage procedure may not be optimal for reconstructing residual cleft defects.

Entamoeba infected orbital cysts as a late complication to orbital floor fractures

An unusual late complication to an orbital floor fracture is presented. Five years after trauma a now 22-year old man demonstrated an entamoeba infected cyst in the orbit.

Volumetry of bone grafts by three-dimensional computed tomographic reconstruction: an animal study in the minipig

OBJECTIVES

To evaluate the accuracy of 3D-CT reconstruction for determination of bone graft volume in an animal model.

MATERIALS AND METHODS

Eight minipigs had bone graft reconstruction of an alveolar ridge defect. The true volume of the graft (VOL I) was determined by Archimedes principle before reconstruction. Following fixation, axial CT-scans (1 mm slice thickness with 50% overlap) were performed and segmented into grafted and residual bone for 3D-reconstruction. Using the volume tool of the 3D program the volume (VOL II) was calculated.

RESULTS

There was a strong correlation between VOL I and VOL II (r = 0.93, P = 0.001). There was a tendency, which was not statistically significant, to overestimate the volume measured by 3D-CT.

CONCLUSION

The volume of a bone graft can be determined by 3D-CT. However, further refinements of the technique are needed to improve the accuracy.

Identification of functional domains on human interleukin 10

Interleukin 10 (IL-10) is a recently described natural endogenous immunosuppressive cytokine that has been identified in human, murine, and other organisms. Human IL-10 (hIL-10) has high homology with murine IL-10 (mIL-10) as well as with an Epstein-Barr virus genome product BCRFI. This viral IL-10 (vIL-10) shares a number of activities with hIL-10. IL-10 significantly affects chemokine biology, because human IL-10 inhibits chemokine production and is a specific chemotactic factor for CD8+ T cells. It suppresses the ability of CD4+ T cells, but not CD8+ T cells, to migrate in response to IL-8. A nonapeptide (IT9302) with complete homology to a sequence of hIL-10 located in the C-terminal portion (residues 152-160) of the cytokine was found to possess activities that mimic some of those of hIL-10. These are: (i) inhibition of IL-1beta-induced IL-8 production by peripheral blood mononuclear cell, (ii) inhibition of spontaneous IL-8 production by cultured human monocytes, (iii) induction of IL-1 receptor antagonistic protein production by human monocytes, (iv) induction of chemotactic migration of CD8+ human T lymphocytes in vitro, (v) desensitization of human CD8+ T cells resulting in an unresponsiveness toward rhIL-10-induced chemotaxis, (vi) suppression of the chemotactic response of CD4+ T human lymphocytes toward IL-8, (vii) induction of IL-4 production by cultured normal human CD4+ T cells, (viii) down-regulation of tumor necrosis factor-alpha production by CD8+ T cells, and (ix) inhibition of class II major histocompatibility complex antigen expression on IFN-gamma-stimulated human monocytes. Another nonapeptide (IT9403) close to the NH2-terminal part of hIL-10 did not reveal cytokine synthesis inhibitory properties, but proved to be a regulator of mast cell proliferation. In conclusion, we have identified two functional domains of IL-10 exerting different IL-10 like activities, an observation that suggests that relatively small segments of these signal proteins are responsible for particular biological functions.

Monocyte chemotactic and activating factor (MCAF/MCP-1) has an autoinductive effect in monocytes, a process regulated by IL-10

MCAF (MCP-1) a member of the chemokine-beta-family known to be chemotactic for monocytes is believed to play a significant role in several inflammatory processes, both immuno-pathological disorders, such as atherosclerosis, psoriasis, chronic inflammatory diseases of the liver and lungs, and during the normal immune response against microorganisms. This chemokine is produced spontaneously by monocytes, and in the present article we also demonstrate that MCAF induces its own production in monocytes. The methods used are two dimensional SDS-PAGE gel electrophoresis. Western-blotting and ELISA quantification of supernatant from monocyte cultures stimulated with MCAF (1, 10, 100 ng ml). Also, we found that this process is regulated by IL-10 (100 ng ml). Our results suggest that monocytes migrating to a site of inflammation due to the local production of the chemokine MCAF/MCP-1 further enhance the focal accumulation of monocytes by producing and releasing bioactive MCAF MCP-1.

Comparison of the reliability of craniofacial anatomic landmarks based on cephalometric radiographs and three-dimensional CT scans

OBJECTIVE

Conventional cephalometry is an inexpensive and well-established method for evaluating patients with dentofacial deformities. However, patients with major deformities, and in particular asymmetric cases are difficult to evaluate by conventional cephalometry. Both two- and three-dimensional computed tomography (CT) have been proposed to alleviate some of these difficulties. Only a few studies using metallic markers have indicated 3-D CT to be a useful diagnostic method, whereas no studies have evaluated the reliability of the anatomic cephalometric points used in 3-D CT. The aim of our study therefore was to compare the reliability of anatomic cephalometric points from conventional cephalograms and 3-D CT.

METHODS

Nine human dry skulls were CT scanned. In addition standard lateral and frontal cephalograms were obtained. The CT scans were 3-D image reconstructed, and the cephalometric points were recorded as x, y, and z co-ordinates by two investigators. Computerized cephalometrics were performed-on the lateral and frontal cephalograms. Intra- and interindividual variations were calculated for each method and tested for statistical significance.

RESULTS

Lateral cephalogram measures were more reliable than 3-D CT, with interobserver variations less than 1 mm for most points compared to about 2 mm for 3-D CT. Lateral cephalometrics also showed significantly less interobserver variation for six variables. This was, however, less obvious when 3-D CT was compared to frontal cephalograms. Frontal cephalometrics showed significantly less interobserver variation for three of the investigated variables.

CONCLUSIONS

For standard lateral and frontal cephalometric points, there is no evidence that 3-D CT is more reliable than the conventional cephalometric methods in normal skull, and the benefit of 3-D CT cephalometric is indicated to be in the severe asymmetric craniofacial syndrome patients, as conventional cephalometrics is known to be inferior in these cases.

An extended Le Fort I osteotomy for correction of midface hypoplasia: a modified technique and results in 35 patients

PURPOSE

This report analyzes the long-term results of a transoral high Le Fort I osteotomy (mean observation period, 37 months).

PATIENTS AND METHODS

Thirty-five patients were treated with high Le Fort I osteotomies in which the zygomatic prominence was included in the osteotomy and advanced together with the maxilla. Twenty of the 35 patients were seen for long-term follow-up (mean, 37 months), which included clinical and radiographic examinations and anamnestic evaluation of the results. In nine patients it was possible to evaluate stability of the osteotomy by cephalometry.

RESULTS

The treatment results clinically appeared stable, with good occlusion and, in most patients, improved function of the masticatory system. Patients reported satisfactory esthetic results. Radiologically the SNA angle was unaltered in six of seven non-CLP (cleft lip and palate) patients and was decreased in two of two CLP patients. There were few complications; one patient had the maxilla reoperated because of a lack of osseous healing and one patient had pulp necrosis of three maxillary teeth.

CONCLUSION

The results achieved with the described method indicate that the use of minor modifications of routine surgical procedures in conventional orthognathic surgery can improve esthetic results in patients with extended midfacial hypoplasia.

Pain control after dental surgery: a double-blind, randomised trial of lornoxicam versus morphine

Lornoxicam is a new non-steroidal anti-inflammatory drug of the oxicam class. This randomised, double-blind, placebo controlled trial compared the analgesic efficacy and tolerability of intramuscular (IM) injections of lornoxicam (4, 8, 16 and 20 mg) with morphine (10 and 20 mg) and placebo in 252 patients with mainly moderate to severe pain following surgical removal of an impacted mandibular third molar. Patients treated with lornoxicam or morphine experienced a significantly greater cumulative pain relief over the 4-h post-injection period (TOTPAR0-4) than placebo recipients. This effect appeared to be dose-dependent, with patients in the lornoxicam 4 mg or morphine 10 mg groups recording significantly lower TOTPAR0-4 scores than patients in the higher dosage groups of these drugs. No significant difference was detected between the morphine 20 mg group and the lornoxicam 8, 16 and 20 mg groups. Lornoxicam was well tolerated at all doses and was associated with a significantly lower incidence of adverse events than morphine 10 or 20 mg. Thus, the analgesic efficacy of IM lornoxicam at doses > or = 4 mg is superior to placebo, and doses > or = 8 mg are at least as effective as IM morphine 20 mg. Furthermore, lornoxicam possesses a more favourable tolerability profile than morphine and thus represents an attractive alternative for the treatment of moderate to severe acute pain.

A comparison of three-dimensional computed tomography scans and stereolithographic models for evaluation of craniofacial anomalies

PURPOSE

This article describes the use of stereolithographic (SL) models as an adjunct to treatment planning in patients with Apert's syndrome, scaphocephaly, brachycephaly, and turricephaly.

PATIENTS AND METHODS

Four syndrome patients had computed tomography (CT) scans done presurgically, and one of these patients was additionally scanned postoperatively. SL models and three-dimensional (3D) CT image reconstructions were produced from the CT data, and linear measurements were compared between the two modalities.

RESULTS

All cases showed mean differences between measurements with 3D-CT and SL models of -0.3 to 0.8 mm, except on the CT scans with a gantry tilt (-1.7 mm) and the brachycephalic patient in whom larger deviations were demonstrated (-9.5 mm).

CONCLUSION

The results of the study indicate that the accuracy of the SL technique is not always sufficient, necessitating additional validation studies before it can be recommended for routine clinical use.

IL-8 induces T cell chemotaxis, suppresses IL-4, and up-regulates IL-8 production by CD4+ T cells

Interleukin-8 (IL-8), a neutrophil-activating cytokine, also activates certain T cell functions such as chemotaxis. We additionally find (n = 6) that recombinant (rIL-8; 1-100 ng/ml), when added to 24 h culture of human CD4+ T cells, suppressed the spontaneous production of IL-4 (50-85%). Steady state production of Il-4 was typically around 30 pg/ml, determined by use of a solid- phase immunoabsorbant assay. De novo synthesis of IL-4 from CD4+ T cells cultured for 3 days was also evaluated by use of detection of [35S]methionine incorporation, as visualized by autoradiography of 2-D gels, and showed that IL-8 suppressed IL-4 production. This suppression of IL-4 production was confirmed in the cytosol fraction by use of Western blotting. The effect of IL-8 (100 ng/ml) was comparable to that of 10 ng/ml recombinant interferon-gamma, both strongly suppressing IL-4 production. The regulatory effect of IL-8 on IL-4 production was also indicated by the fact that addition of a neutralizing monoclonal anti-IL-8 antibody (WS.4) enhanced the spontaneous IL-4 production when added to the culture of CD4+ T cells, thereby probably inactivating the effect of IL-8 originating from the cultured T cells. Also, we observed that IL-4 mRNA expression was down-regulated when the CD4+ T cells were cultured for 12 h in the presence of 100 ng/ml IL-8. The suppression of IL-4 mRNA expression could be prevented by adding anti-IL-8 (20 microgram/ml) or IL-10 (100 ng/ml) l h before adding rIL-8. Thus, IL-8 may be an important regulator of CD4+ T cell-derived IL-4, thereby possibly regulating the balance between humoral and cellular T cell-dependent responses.

Transverse dentofacial structure of young men who have undergone surgical correction of unilateral cleft lip and palate: a posteroanterior cephalometric study

The transverse dentofacial structure of 34 young adult males with unilateral cleft lip and palate, studied by means of posteroanterior cephalograms, was compared to that of a normal sample of 102 young adult males. All cleft patients had been treated surgically and orthodontically in accordance with a standardized protocol. Orthognathic surgical treatment was carried out when growth had ended in a few subjects. In studying the posteroanterior cephalograms, eight lengths, 10 ratios, and three angular variables were used. Comparison of the cephalometric values of the subjects with cleft palate and the normal sample of young adult males indicated (1) the absence of any significant differences in angular variables describing the transverse dentoalveolar relationships in the maxillary and mandibular incisal regions as well as the mandibular position; (2) the absence of any significant differences in the ratios of the nasal, maxillary, and mandibular widths to the interorbital width; (3) the presence, in the cleft group of significantly decreased ratios of maxillary intermolar width to interorbital width, mandibular intermolar width to interorbital width, maxillary intermolar width to mandibular intermolar width, and maxillary intermolar width to maxillary width; (4) the presence, in the cleft group, of a significantly increased ratio of innerorbital width to interorbital width; and (5) significant correlations between the maxillary and mandibular molar widths in the cleft group.

A randomized, double-blind, placebo-controlled, dose-response study of the analgesic effect of lornoxicam after surgical removal of mandibular third molars

The aim of the present study was to investigate the dose-effect relationship of single doses of 4 to 32 mg of lornoxicam (LNX), a new nonsteroidal antiinflammatory drug belonging to the oxicam group, compared with placebo and 10 mg ketorolac (KET) in the treatment of pain after oral surgery. Also, it was the aim of the study to evaluate the relationship between adverse events and different doses of LNX. After the surgical removal of a mandibular third molar, test medication was taken when the patients experienced at least moderate pain. After medication, pain relief, pain intensity, and any discomfort from the medication were noted in a questionnaire. Paracetamol was used as rescue medication. A total of 278 patients completed the study according to the protocol. The primary efficacy parameter was total pain relief after 6 hours, and all active treatments showed significantly better effect than placebo, with LNX 16 and 32 mg being significantly superior to LNX 4 mg. All other efficacy parameters showed the same dose-effect relationship. A total of 37 adverse events were reported evenly distributed in the 6 treatment groups; only 3 of these were considered severe, and all disappeared without treatment. In conclusion, the study showed a dose-effect relationship of LNX without a rise in adverse events. The effect of 10 mg KET seemed to be at the level of 8 to 16 mg LNX.

A retrospective analysis of 279 patients with isolated mandibular fractures treated with titanium miniplates

PURPOSE

This article addresses the suitability of semirigid fixation for the treatment of mandibular fractures.

MATERIALS AND METHODS

Between 1986 and 1991, 279 patients with 447 isolated mandibular fractures were treated with miniplate fixation using the tension-band principle of Champy et al. The time from trauma to treatment, etiology, number and location of the fractures, and the presence of preoperative infection and neurosensory disturbances were recorded. Postoperative complications such as infections, neurosensory disturbances, malocclusion, and nonunions also were recorded, as well as the reasons for removal of the miniplates.

RESULTS

Postoperative infection occurred in 10 patients (3.6%). These infections were controlled by antibiotics and the miniplates were removed after the acute phase. Occlusion disturbances were noted postoperatively in 13 patients (4.7%), and they were corrected by minimal occlusal grinding in the majority of cases. Neurosensory disturbances were noted preoperatively in 26.9% of the patients and 12 months postoperatively in 1.4% of the patients. Forty-seven plates (8.1%) in 32 patients (11.5%) were removed for a variety of reasons. No cases of nonunion occurred.

CONCLUSION

Semirigid fixation of mandibular fractures with miniplates is a viable treatment option for the management of such injuries.

Nerve transposition and implant placement in the atrophic posterior mandibular alveolar ridge

The results obtained with a modified surgical technique for transposition of the inferior alveolar nerve followed by immediate placement of endosseous implants in mandibles with moderate to severe atrophy are presented. Ten transpositions of the inferior alveolar nerve together with the installation of 21 implants were performed in six patients. The mean postoperative follow-up time was 23 months, with a range of 12 to 46 months. All implants with functioning pontics remained stable, with no mobility nor signs or symptoms of pain and infection during the follow-up period. Postoperative radiographic evaluation disclosed no pathologic bone loss around the implants. Neurosensory evaluation was performed using the two-point discrimination test. One patient with unilateral transposition had objective neurosensory dysfunction at 12 months postoperative, although all the nerve function were reported as normal by the patients. Strict patient selection criteria are necessary, with full awareness by the patient of the possibility of long-term or even permanent nerve paresthesia, when this procedure is contemplated.

Varying treatment strategies for reconstruction of maxillary atrophy with implants: results in 98 patients

This report describes the outcome of maxillary implant reconstruction in 98 consecutively treated patients assigned to three groups based on the degree of maxillary atrophy as noted on radiographic examination and method of treatment. In group 1, 33 patients had 83 implants installed following sinus and/or nasal mucosal lift procedures. In group 2, 26 patients had 56 implants placed that penetrated the sinus and/or nasal cavities. The penetrating portion of the implant was covered with autogenous particulate bone harvested from the lateral aspect of the ipsilateral sinus. In group 3, 39 patients had 152 implants fixed to autogenous mandibular bone grafts placed either in the antral and/or nasal floors and/or as an onlay over the residual alveolar ridge. The age range of the patients was 15 to 76 years, with a mean of 56 years. Follow-up periods ranged from 12 to 58 months, with a mean of 26 months. Of the 291 implants installed, 19 have been lost. The importance of considering different treatment strategies when reconstructing the edentulous maxilla is discussed.

Pediatric condylar fractures: a long-term follow-up study of 55 patients

Fifty-five patients between 5 and 20 years old who were previously treated conservatively for a fracture of the mandibular condyle were recalled for follow-up examination with a mean postoperative observation time of 10.1 years. Anamnestic information was obtained from a questionnaire, and clinical and radiologic examinations were performed. Anamnestic and clinical dysfunction indices were obtained. When the patients were divided into four different age groups it was found that the dysfunction index values increased significantly with increasing age at the time of trauma. Radiologic abnormalities such as reduced ramus height, deviation of the mandibular midline, and irregular shape of the condyle were seen frequently, but could not be correlated with the severity of dysfunction. No cases of ankylosis or serious asymmetry were found. The results support the opinion that conservative treatment is sufficient in pediatric patients, but in older age groups the results of conservative treatment are less satisfactory.

Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants

The hemostatic effect of tranexamic acid solution (4.8%) used as a mouthwash was compared with a placebo solution in 93 patients on continuous, unchanged, oral anticoagulant treatment undergoing oral surgery. The investigation was a randomized, double-blind, placebo-controlled, multicenter study. Before suturing, the surgically treated region was irrigated with 10 mL of tranexamic acid (46 patients) or placebo (47 patients) solution. The patients then performed mouthwash with 10 mL of the solution for 2 minutes four times daily for 7 days. The treatment groups were comparable regarding age, smoking habits, and surgery. Laboratory variables measuring vitamin K-dependent coagulation factors were within therapeutic ranges (international normalized ratio 4.00 to 2.10). One of the clinics used a different method for these measurements and therefore the levels of coagulation factor X in plasma obtained for the three clinics were compared. No significant difference in the range at which surgery was performed was found between clinics. In the placebo group, 10 patients developed bleeding requiring treatment, while none of the patients treated with tranexamic acid solution had bleeding. This difference was statistically significant (P < .01). The treatment with mouthwash was well tolerated. It was concluded that patients on oral anticoagulants can undergo oral surgery within the therapeutic range without reducing the dosage of anticoagulants, provided that local antifibrinolytic treatment with tranexamic acid solution is instituted.

Central hemangioma of the mandible

Central hemangioma of the mandible is a relatively rare condition; when it occurs, the clinical and radiographic presentation are often nonspecific. A proper diagnosis can be made with a high level of clinical suspicion, and imaging studies such as angiography can confirm the suspicion that a vascular lesion exists and can contribute valuable information to the preoperative data base. We report three cases of central hemangioma of the mandible demonstrating the variability of signs and symptoms and review the various treatment alternatives in the literature. We suggest that the treatment of choice for this entity is surgery, including reconstruction as necessary.

Rigid fixation in reconstruction of craniofacial fractures

Ninety-four patients had either isolated fractures of the skull or midface, or combined fractures of the skull, periorbit, and/or midface. Thirty-five of these patients were treated by conventional methods, including maxillomandibular fixation (MMF) 4 to 6 weeks postoperatively, wire osteosynthesis, suspension ligatures, or a head frame. The remaining 59 patients were treated with either mini-, low-profile, micro-, or 3-D titanium plate fixation (rigid internal fixation [RIF]) and comprise the patient population for this study. Of the 59 patients, 11 were female and 48 male, ranging in age from 6 to 85 years, with a mean age of 34 years. Six patients had isolated skull fractures, 9 had combined skull and periorbital fractures, 31 had isolated midface fractures, and 13 patients had combined skull and midface fractures. The follow-up period ranged from 3 to 48 months. Patients with midface fractures were placed in MMF intraoperatively, and MMF was released at the completion of the procedure. At 2 to 4 days postoperatively, the occlusion was evaluated. Fifteen of the 38 dentate patients with either midface or combined skull and midface fractures were without MMF postoperatively. Twenty-three patients showed slight occlusal discrepancies and were treated with elastic MMF for 3 to 28 days (mean, 10 days). All reductions were judged to be stable throughout the postoperative course. Based on the results, use of RIF is recommended for primary reconstruction in craniofacial trauma patients whenever possible, thereby achieving three-dimensional stability, sufficient functional and cosmetic results, and often avoiding or reducing the need for MMF.

Arthroscopy of the human temporomandibular joint

This paper reviews the indications, technique and results of arthroscopy of the human TMJ. Our results in arthroscopic treatment of 36 patients (48 joints) are reported and the results are comparable with previously reported results. Mainly internal derangements with closed lock and preauricular pain have been treated and in all cases a single puncture technique followed by a blunt sweep procedure was used. All patients have before arthroscopy received a conservative treatment with insufficient result. It is concluded that arthroscopy is an excellent tool in diagnosis and treatment of TMJ disorders. However TMJ arthroscopy should be regarded as a supplement to conventional therapy and an alternative to open joint surgery.

Autogenous mandibular bone grafts and osseointegrated implants for reconstruction of the severely atrophied maxilla: a preliminary report

The purpose of this study is to present results obtained with a new procedure for reconstruction of the severely atrophied maxillary alveolar ridge that involves the use of intramembranous corticocancellous bone grafts obtained from the mandibular symphysis fixed to the residual bone by endosseous implants. A total of 107 implants were installed in grafted regions in 26 patients. The follow-up period ranged from 6 to 32 months, with a mean of 16 months. In partially edentulous patients the bone grafts were fixed with implants to the residual bone as 1) onlay graft to the alveolar ridge (8 implants in 4 patients); 2) grafts to the nasal and/or sinus floor after a transoral exposure and elevation of the mucosa of the maxillary sinus and/or the nasal mucosa (33 implants in 11 patients); or 3) a combination of these two (5 implants in 2 patients). In totally edentulous patients, implants and grafts were used as a combination of grafting to both the alveolar ridge and nasal and/or sinus floor sites (61 implants in 9 patients). One hundred of 107 implants showed normal clinical and radiologic healing, whereas 7 implants in 4 patients (6.5%) were lost prior to loading. Seventeen patients have had the implants and bone grafts loaded by a prosthodontic reconstruction from 6 to 26 months (mean, 14 months) without loss of any implants. Postoperative marginal resorption of the onlay bone graft of less than 15% was observed. These findings suggest, that the previously observed rapid resorption of endochondral iliac crest onlay bone grafts and the number of lost implants can be significantly reduced if bone from the mandibular symphysis firmly anchored with titanium implants is used.

Haemostasis in oral surgery--the possible pathogenetic implications of oral fibrinolysis on bleeding. Experimental and clinical studies of the haemostatic balance in the oral cavity, with particular reference to patients with acquired and congenital defects of the coagulation system

Activation and inhibition of the haemostatic system was reviewed including the interaction between the four biological systems involved in haemostasis: the vessel wall, the platelets, the coagulation system and the fibrinolytic system. The haemostatic mechanism is initiated at the site of injury through local activation of surfaces and release of tissue thromboplastin, resulting in formation and deposition of fibrin. The coagulation process is regulated by physiological anticoagulants. Activation of fibrinolysis is triggered by the presence of fibrin, and the role of tissue-type plasminogen activators (t-PA) at the site of fibrin formation in particular is emphasized. The process is regulated by physiological inhibitors, of which alpha 2-antiplasmin, histidine-rich glycoprotein and plasminogen activator inhibitor are reported to be of major physiological significance. The role of fibrinolysis in the regulation of the dynamic haemostatic balance is discussed, elucidated through examples of congenital deficiencies of the coagulation and the fibrinoytic system. Pharmacological inhibitors of fibrinolysis (i.e. epsilon-aminocaproic acid and tranexamic acid) and their possible effect on the haemostatic system are described. The systemic effects on the fibrinolytic system of surgery and oral surgery is reviewed, and it is concluded, that oral surgery has insignificant effects on blood fibrinolysis. In contrast, oral surgery induces changes of fibrinolysis in the oral environment; initially the fibrinolytic activity of saliva is reduced, due to the presence of inhibitors of fibrinolysis originating from the blood and the wound exudate. When bleeding and exudation cease, the fibrinolytic activity of the saliva will increase. Plasminogen and plasminogen activator, identified as t-PA are present in the oral environment under physiological conditions. Plasminogen is secreted in the saliva and the sources of t-PA include oral epithelial cells and gingival crevicular fluid. The presence of plasminogen and t-PA in the oral environment implies that when fibrin is present (i.e. after surgery), fibrinolysis is triggered. Haemorrhagic complications to oral surgery in patients without known defects of the coagulation system is reviewed. It is concluded that the investigations conducted to the present day do not permit final conclusions with respect to the pathophysiological role of defects in the coagulation and the fibrinolytic systems for the development of bleeding after oral surgery. Further investigations are necessary in order to clarify these aspects, and should include extensive laboratory analyses to reveal rare congenital defects such as factor XIII- and alpha 2-antiplasmin deficiencies.(ABSTRACT TRUNCATED AT 400 WORDS)

The transmandibular implant: a 13-year survey of its use

During the period from August 1976 until July 1989 the transmandibular implant was introduced in a total of 31 oral and maxillofacial surgery departments in the Netherlands and 1,466 patients were treated. This study includes 1,356 treated patients from 28 departments. The treatment course of 1,201 patients (89.6%) was uneventful. Of the 157 complications, 58 related to the anatomic contour of the mandible, 49 to the surgery, 25 to the prosthetic reconstruction, 8 to the psychosocial attitude of the patient, 8 to the use of medication, 5 to trauma, and 4 to the presence of a skin graft. Treatment of the complications included removal of the implant in 44 patients; in 106 patients the complication was treated satisfactorily. In the remaining 7 patients, hypesthesia was present. The reasons for the removal of the 44 implants were infection (11), operative error (5), premature loading of the implant (3), insufficient width of the mandible after a visor osteotomy (1), loss of osseointegration caused by the prosthesis (14), psychological problems (4), trauma (3), drug-related gingival hyperplasia (2), and inexplicable pain (1). The present survey shows a consistent success rate of 96.8%.

[Treatment of edentulousness by use of osteointegrated implants i e Brånemark]

The aim of the study was to evaluate and compare the results of treatment achieved with the Brånemark implantsystem in patients treated in our hospital and patients treated in surgical practice. This study includes 96 patients who received a total of 457 implants. Fifty-two patients were treated in the hospital with 304 implants and 44 patients were treated in practice with 153 implants. Most of the patients treated in the hospital received fixed bridges after a total jaw implant reconstruction. In this group complicating medical diseases and severely altered jaw anatomy have influenced the treatment results for which reason 37 (12%) of implants installed were lost. Treatment of partially edentulousness and single tooth loss with implants was dominating in the group of patients treated in surgical practice. In this group only 3 (2%) implants installed were lost. The results of the present study are comparable with other published reports and indicates that Brånemark implants has a predictably good prognosis. Furthermore, this study has shown that implant treatment significantly improve the prosthodontic function in patients suffering from edentulousness.

Osteoradionecrosis, pathogenesis, treatment and prevention

The present paper discuss the development of osteoradionecrosis (ORN) in the jaws. ORN is the end stage of tissue injury induced by irradiation. The most prominent etiologic factor of ORN seems to be the effect of radiation on endothelial cells lining the vessels. These cells are, as tumor cells, highly radiosensitive, and radiation leads to a vascular damage resulting in hypoxic, hypovascular and hypocellular tissues. Wound healing in such tissues is impaired since nutritional demands of the wound, including oxygen, cannot be supplied due to the degenerative changes in the blood vessels. The paper furthermore describes the scientific basis for the use of hyperbaric oxygen therapy (HBO) in ORN. HBO increase the vascularity in the tissues injured by radiation, and thus tissue viability and healing capacity is increased reducing the risk for spontaneous or traumainduced ORN. Protocols for the treatment of patients with ORN are presented and prophylactic guidelines are described.

[Use of titanium osteosynthesis in maxillofacial traumatology and orthognathic surgery]

This paper reviews the clinical use of titanium miniplate osteosynthesis in maxillofacial traumatology and orthognathic surgery. These materials were originally developed for treatment of mandibular fractures, but the application has within recent years been extended to other fractures of the facial skeleton and orthognathic surgery. The osteosynthesis increase stability in many situations, and may reduce or eliminate the need for post-operative intermaxillary fixation, by which morbidity, hospitalization period and period of sick-leave can be reduced. In orthognathic surgery, the stability of the miniplate osteosynthesis increase the demand for precision during surgery as compared to conventional fixation with wire osteosynthesis and intermaxillary fixation. Further refinements of the technique are, however, necessary in the future, as the current techniques does not always allow a sufficient reproduction of the position of the condylar segment.

Intermaxillary fixation of mandibular fractures with the bracket-bar

An alternative method for intermaxillary fixation of mandibular fractures using a bracket-bar bonded to the teeth is described. The technique is easy to use, improves gingival health, reduces anaesthesia time and reduces the risk of transmitting blood-borne diseases to the surgeon through perforating injuries from wires.