Brian Alpert

Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures.

Internal fixation devices in the form of bone plates have been used for a long time in maxillofacial surgery. As early as 1907, Albin Lambotte of Belgium’ reported the fixation of a mandibular fracture with “a little aluminum plate fixed with two screws.” In North America, Thorna,’ Archer,” Robinson

The microbiologic flora of orofacial abscesses

5 Dingman and Natvig,6 Richter and Boyney and Hahn and Corgill’,’ advocated plate or mesh fixation for fractures or in reconstructive surgery of the jaws. These devices and techniques were designed as adjuncts in the management of specific injuries and/or congenital or acquired deformities. Primarily, they were designed to supplement conventional maxillomandibular fixation, contain graft systems, or provide structure and contour. In Europe, Luhr,” Spiessl,” Schilli,12 and Champy et al” developed and/or popularized internal fixation systems involving plates and screws that were designed to avoid or eliminate the need for maxillomandibular fixation in the treatment of maxillofacial injuries and deformities. Their techniques and devices, as well as their philosophy of care, were generally accepted in Europe by the late 1970s and in North America by the late 1980s. The early plating systems were generally large and bulky (other than the Champy system) and fabricated of stainless steel (Spiessl, Champy) or chrome cobalt (Luhr). Removal after they ceased to function was advocated as part of total management. North American surgeons questioned the need for removal, pointing out that patients would not accept a second surgery nor

Experience with rigid fixation of mandibular fractures and immediate function

Fifty orofacial abscesses were studied using culture techniques for both aerobic and anaerobic organisms. Eighty-six per cent of the specimens contained anaerobes; of this group, 39 per cent had organisms resistant to penicillin.

Management of Atrophic Edentulous Mandibular Fractures: The Case for Primary Reconstruction With Immediate Bone Grafting

The results of using rigid fixation for 75 mandibular fractures in 52 patients and allowing immediate function were retrospectively analyzed. Sixteen percent of fractures developed postoperative infection. All infections were in fractures associated with teeth; none occurred in fractures fixed within 24 hours of injury. Angle and posterior body fractures were most likely to become infected. Fractures with improperly applied rigid fixation also were subject to a high infection rate. It was unusual for infection involving this type of treatment to prolong the course of therapy or affect the final outcome.

Management of comminuted fractures of the mandible.

t s m c n trophic edentulous mandibular fractures, particuarly bilateral fractures (Fig 1) have always posed a roblem for not only those who suffer them, but lso for the treating surgeon. The patients are often lderly and infirm. The bone is brittle; often the onsistency of porcelain, the surface area is quite mall, and the entire bone-periosteal complex has arkedly diminished healing capacity. Opposing uscle groups come into play, both displacing and indering reduction of the fractures and comproising stability. The diminished surface area of the racture allows no load sharing capacity, and the one adjacent to the fracture does not lend itself to crew fixation. The construction of accurate dental plints is difficult if not impossible to achieve. All of hese factors can mitigate the successful outcome

The in vivo behavior of gentamicin-PMMA beads in the maxillofacial region.

Comminuted fractures of the mandible are unusual but not rare. They are complex injuries with a high complication rate. Gunshot wounds are a frequent cause. Traditional management with closed techniques is noted for good long-term results, but may involve an extended period of treatment. Treatment with open reduction and rigid internal fixation significantly shortens the course of treatment and simplifies the convalescence.

Well-circumscribed mass of the lateral floor of the mouth

Gentamicin-PMMA beads were placed in maxillofacial wounds of ten dogs, and gentamicin levels from wound drain sites, serum, and urine were measured by radioimmunoassay. The results indicate extremely high wound and modest urine levels (which decrease exponentially) concurrently with negligible serum levels of gentamicin. The results of this study of a highly vascularized area were similar to other studies in which beads were placed in avascular areas.

Failed Fixation in Atrophic Mandibular Fractures: The Case against Miniplates

In June 1990. a 67-year-old woman was referred to the Oral and Maxillofacial Surgery Clinic for evaluation and treatment of an asymptomatic, firm swelling in the right anterior floor of the mouth. The patient’s chief complaint was an ill-fitting maxillary full denture and mandibular partial denture. The patient had been unaware of the mass. The patient’s medical history was significant for bilateral acoustic neuromas, which were removed surgically, one in 1981. the other in 1986. The patient was left with total bilateral deafness and mild seventh cranial nerve weakness bilaterally. The patient also had bilateral cataracts that were treated surgically 4 years previously. The patient’s health and family history were otherwise noncontributory. She was not taking medications and denied a history of drug allergies. On clinical examination, the patient appeared to be a thin. elderly woman without acute distress. She was afebrile and her vital signs were stable. Examination of the head and neck revealed a soft. discrete swelling of the right submental area. without any other significant findings. The floor of the mouth on the right was slightly elevated above the partially edentulous atrophic mandibular alveolar ridge (Fig 1). A nonpainful, ill-defined, freely movable, rubbery mass measuring 3.0 by 2.5 cm in diameter was palpable above the mylohyoid muscle. The overlying mucosa was nonulcerated and appeared normal. The mass did not appear to contribute to the ill fit of the lower partial denture. Salivary flow from Wharton’s ducts was clear and abundant bilaterally. A mandibular occlusal radiograph failed to disclose any abnormalities. Magnetic resonance imaging (Tz-weighted) revealed a 2.7 X 2.2-cm area of increased signal intensity in the right floor of the mouth (Fig 2). Patient movement limited the diagnostic value ofthe study. She was scheduled for an incisional biopsy in the outpatient oral surgery clinic under local anesthesia.

Bisphosphonate-related osteonecrosis of the jaws.

Despite advances in the treatment of the fractured atrophic edentulous mandible, treatment continues to be difficult. Patient management is more complicated due to patients often being elderly with more complex medical problems. Rigid internal fixation has greatly improved outcomes with shorter treatment times, yet a consensus has yet to be reached regarding which method yields the most predictable results. Options include using small miniplates to larger reconstruction plates. Although each method has advantages, we present our experience with retreatment of failed miniplate fixation using load-bearing reconstruction plates of fractured atrophic edentulous mandibles.

Contemporary management of infected mandibular fractures.

Purpose of reviewThe purpose of this article is to review a new pathologic entity named bisphosphonate-related osteonecrosis of the jaws (BRONJ). Recent findingsBRONJ was observed and first reported in 2001–2002 when clinicians noticed cases of refractory osteomyelitis after simple dental procedures such as dental extractions in patients who had received bisphosphonate therapy. The condition was initially seen in patients who received i.v. bisphosphonates for malignancies such as multiple myeloma and metastatic breast cancer. However, with the use of bisphosphonate therapy for osteoporosis, BRONJ is seen in patients without a cancer diagnosis. SummaryThe incidence of BRONJ remains unclear. Treatment recommendations based on sound scientific data are sparse. The management of BRONJ remains a difficult and controversial situation that continues to challenge the clinician.