D. Wiesenfeld

Orofacial granulomatosis – a 20-year review

Orofacial granulomatosis (OFG) is the presence of persistent enlargement of the soft tissues of the oral and maxillofacial region, characterized by non-caseating granulomatous inflammation in the absence of diagnosable systemic Crohns disease (CD) or sarcoidosis. Over 20 years have passed since OFG was first described and an extensive review of the literature reveals that there is no consensus whether OFG is a distinct clinical disorder or an initial presentation of CD or sarcoidosis. Furthermore, the precise cause of OFG is still unknown although several theories have been suggested including infection, genetic predisposition and allergy. The clinical outcome of OFG patients continues to be unpredictable. Current therapies remain unsatisfactory. Regular clinical review is indicated to identify the development of gastrointestinal or systemic involvement. The aim of this review was to analyse the developments in our understanding of the aetiology, pathogenesis and treatment protocols, with particular emphasis on management and outcomes of OFG since this entity was first described in 1985.

Referral patterns of patients with oral squamous cell carcinoma, Australia

Early diagnosis is an important factor affecting the prognosis of patients with oral cancer. Delays in diagnosis have been variously reported as being linked to the patient, the clinician or both. The purpose of this study was to investigate the referral patterns of patients with oral cancer by medical and dental practitioners, in order to assess the delays in diagnosis and to establish the reasons for these delays. 51 consecutive patients diagnosed with oral mucous membrane squamous cell carcinoma were retrospectively reviewed. In this study it was found that over one-third of the patients (38%) delayed seeking professional advice for more than 3 months after first being aware of the lesion. Initial delays in diagnosis of oral cancer was identified in one-third of the cases (17 patients), with antimicrobial medications prescribed and denture adjustments constituting the most frequently administered inappropriate therapy. General medical practitioners were more likely to encounter and refer patients with more advanced (T4) primary oral cancers than their dental colleagues. The findings of this study raise the concern that lack of patient awareness and inappropriate clinical management prevails in a community that should be better informed.

Maxillary ameloblastoma: a retrospective study of 13 cases.

Ameloblastoma is uncommon in the maxilla, comprising about 15% of all reported ameloblastomas. Ameloblastomas are locally aggressive and, when involving the maxilla, potentially lethal. The long term outcome of 13 patients with ameloblastoma in the maxilla for whom surgery was the primary treatment between 1951-1990 was studied. Patient records from both private and public practices in Melbourne, Australia were examined as were those cases reported to the Bone Tumour Registry at the University of Bristol, England. The study showed that control of disease was achieved in all patients where the tumour was limited to the confines of the maxilla (10 cases). The mean follow-up period in this group was 7 years (range 2-20 years). In the three cases that recurred all had preoperative radiological evidence of posterior maxillary sinus wall destruction and/or pterygoid plate erosion. Two patients died of extensive local recurrence and one has persistence of the disease. Histopathological examination confirmed the diagnosis of ameloblastoma in each case with a variety of histological patterns being noted. It is concluded that notwithstanding histological type, the extent of the tumour at presentation and the adequacy of the surgical approach and removal were the main factors in successfully managing the disease.

The use of titanium mandibular reconstruction plates in patients with oral cancer

A series of 21 patients, who were selected for primary mandibular stabilisation with titanium plates following excision of advanced malignant tumours, is reported. Success was defined as a plate that did not have to be removed due to fracture, exposure or infection. The overall success rate was 71%, with follow-up ranging from 7-53 months. The majority of plate losses were experienced when either anterior or large lateral defects which included the condyle were bridged and when patients were subjected to either pre- or postoperative radiotherapy.

Allergy to dental gold

Allergy to gold dental appliances in very rare. This article reports the case of a patient who presented with acute oral ulceration following the placement of a gold crown. Biopsy of the ulcer and adjacent mucosa showed histologic features typical of a contact sensitivity. The patient subsequently had a positive patch test reaction to gold chloride. The literature is reviewed, and the dental implications are discussed.

Mandibular fracture osteosynthesis: a comparison of three techniques

The authors report on a retrospective study of 205 consecutive patients at the Maxillofacial Unit of The Royal Melbourne Hospital to assess if adherence to Champys principles in placement of miniplates in mandibular fractures minimises morbidity. 205 well documented cases of mandibular fractures treated with internal fixation, January 1985 to April 1990 were studied. The patients were assigned into three groups according to the type of fixation; 83 patients had miniplate fixation according to Champys principles, 40 patients had miniplate fixation ignoring Champys principles, 82 patients had transosseous wire (TOW) fixation. Outcome was measured by preoperative variables (age, gender, mechanism of fracture, site and number of fractures, nerve function, associated injuries and treatment delay) and postoperative variables (duration of admission, duration of intermaxillary fixation (IMF), malocclusion, infection, dehiscence, union, removal of fixation and nerve function which were assessed and compared. The results show that the preoperative variables were statistically similar in all groups. The postoperative variables indicated a statistically higher complication rate for the transosseous wire group compared with the miniplate groups, and morbidity was reduced in the group following Champys principles. The morbidity rates in this study compare favourably with other studies even though the patients in this study had a much higher incidence of multiple fractures. Titanium miniplates appear as effective as miniplates constructed of other materials used in previous studies, especially when Champys principles are followed.

Temporomandibular pain dysfunction disorder resulting from road traffic accidents — An Australian study

The relationship between temporomandibular pain dysfunction disorder (TMPD) and trauma to the head and neck is unclear. A retrospective analysis of the records from the Transport Accident Commission (TAC) of Victoria, Australia, in the year 1987, was done to identify those subjects who received treatment for TMPD resulting from a road traffic accident (RTA). Twenty-eight subjects with TMPD were identified from a total of 20 673 subjects who claimed health care services from the TAC for RTA-related disorders. In this study, TMPD for which subjects sought treatment was uncommonly associated with either direct or indirect trauma to the temporomandibular joints: 0.4% of subjects with mandibular fractures and 0.5% of subjects with whiplash injuries presented for treatment of an associated TMPD. Females were found to present for treatment of TMPD more commonly than males at a ratio of 5:2. It was also noted that 75% of subjects complained of symptoms of TMPD immediately after the accident and approximately 96% within 2 months of the accident. Subjects were not lost to follow-up because all claims for treatment were made to the TAC, regardless of the clinician involved. In this study, 25% of subjects attended more than one dentist for management. It was concluded that TMPD for which subjects sought treatment was an uncommon result of an RTA and was infrequently associated with a mandibular fracture or whiplash injury.

Mandibular invasion by squamous cell carcinoma: a computed tomographic and histological study.

Our knowledge of the entry and spread of oral cell carcinoma (SCC) into the mandible is increasing, making an impact on surgical planning. Fourteen resection specimens of mandibular bone and adjacent SCC were radiographically (CT) and histologically investigated. In six cases there was no involvement of mandibular bone; a continuous periosteal layer separated the tumour from bone. The remaining eight specimens showed bony involvement with good correlation between corresponding CT and histological slices in the five edentate cases. The site of entry of the tumour into the bone was usually through the alveolar crest with additional spread through the lingual cortex in tumours that lay lingual to the mandible. Although limited, our data shows that the main site of entry of SCC is through the alveolar crest. It also highlights the usefulness of CT in the identification of bone involvement in edentate cases. This information may assist in the planning of operations to preserve as much bone as is consistent with complete excision of the tumour.

Bilateral parotid gland aplasia

Bilateral parotid gland aplasia is a cause of xerostomia. A case is presented in which the clinical diagnosis was confirmed with the use of 99mTcO-4 salivary gland scintiscanning and computerised tomography. The literature of this rare condition is reviewed and significance to the patient discussed.

The anatomy of the facial nerve in relation to CT/sialography of the parotid gland

The technique of computed tomography with simultaneous parotid sialography allows for accurate localisation of tumours within the parotid gland. The relationship of these tumours to the facial nerve, which divides within the gland, is of surgical significance. A study of the course of the facial nerve through the parotid gland in the cadaver was therefore undertaken in order to identify relevant landmarks for the CT prediction of its relationship to those tumours. The heads of five cadavers were sectioned in the Frankfurt plane into 1 cm slices which were then X-rayed. Individual slices were examined and the course of the facial nerve was plotted on the X-ray plate of the same slice. It was found that the nerve could be represented on a CT scan by an arc of radius 8.5 mm, the centre of which is the most posterior point of the ramus of the mandible. The arc extends from directly lateral to directly posterior to that point. Pre-operative visualisation of parotid tumours by simultaneous CT scan and sialography in conjunction with an appreciation of the course of the facial nerve through the parotid gland may allow for more precise presurgical planning.