Gary F. Bouloux

Complications of orthognathic surgery

Evidenced-based medicine criteria are becomingthe standards by which clinical studies are rated [1].Articles that evaluate clinical outcomes can be cate-gorized according to a hierarchy of evidence-basedmedicine. The strongest evidence is that derived fromrandomized, clinical trials or, even better, a meta-analysis of several randomized, controlled trials. Thenextstrongestevidenceisderivedfromcohortstudies.This is followed by evidence that is derived fromcase control series. Isolated case reports provide theweakest evidence in this hierarchy. Numerous chap-ters in various texts have reported a wide spectrum ofcomplications of orthognathic surgery based on allfour of these types of evidence. Little has been addedin the recent literature regarding the range or typesof complications. A few studies have tightened ourfocus on the already known complications of or-thognathic surgery with regard to prevalence andseverity. This article concentrates on studies thatreport complications with the weight of randomizedclinical trials or cohort studies. Where possible, ametaanalysis has been performed to provide the high-est level of evidence-based medicine. Means for allstatistics are weighted to account for the differentsample sizes. Where original publications providedadequate information, confidence intervals (error barson figures) were determined that allow the reader todetermine the range that is required to be 95% certainthat if the study were repeated the new mean wouldfall within that range. Where narrow confidenceintervals are shown, this suggests a high degree ofprecision and reproducibility. When the confidenceinterval crosses the null value (ie, 0%), the results arenot statistically significant, although they may stillbe clinically important.Neurosensory changesInferior alveolar nerve injuryAlthough inferior alveolar nerve (IAN) injury hasbeen reported as a result of several mandibularoperations, its association with the bilateral sagittalsplit osteotomy (BSSO) is well documented [2–8].Evaluation of these studies is confounded by thenumerous techniques that have been used to performthe operation and methods and timing of postsurgicalneurosensory changes. Variations in techniqueinclude the use of burs, saws, blunt or heavy chisels,sharp, thin chisels, and spreaders to complete theosteotomy. The method of fixation may includeinterosseous wiring plus intermaxillary fixation,bicortical lag screws, bicortical position screws,monocortical plates, or a combination of these. Thereis no ‘‘standard technique’’ to provide guidance, andoutcome study comparison is difficult.For BSSO with rigid internal fixation (RIF), thepostoperative incidence of IAN neurosensory lossvaries from 0% to 75% (Table 1), with a mean of35% for subjective reporting and 33% for objectivetesting at a mean follow-up of 21 months [2–8](Fig. 1). The methods of data collection for subjectiveand objective parameters vary considerably, whichwould be likely to influence the results. Whether the

Bupivacaine versus lidocaine for third molar surgery: A double-blind, randomized, crossover study☆

PURPOSE The aim of this study was to compare the clinical use of bupivacaine to lidocaine in third molar surgery. PATIENTS AND METHODS Twenty-three subjects underwent surgical removal of their third molars in two separate procedures. Bupivacaine was used for the third molars on one side, whereas lidocaine was used on the other side. Pain experience, analgesic consumption, cardiovascular response, blood concentrations, and systemic toxicity were evaluated. RESULTS Bupivacaine significantly reduced the postoperative pain experience only at the 8-hour period (P < .05). No difference in analgesic requirements or cardiovascular responses was observed with the two local anesthetics. The mean blood concentrations of both agents were considerably lower than their respective toxic threshold concentrations. CONCLUSION The results of this study do not show a difference in a variety of parameters, other than postoperative pain experience, when bupivacaine and lidocaine are compared in a standardized oral surgery procedure.

An integrated understanding of the physiological response to elevated extracellular phosphate

Recent studies have suggested that changes in serum phosphate levels influence pathological states associated with aging such as cancer, bone metabolism, and cardiovascular function, even in individuals with normal renal function. The causes are only beginning to be elucidated but are likely a combination of endocrine, paracrine, autocrine, and cell autonomous effects. We have used an integrated quantitative biology approach, combining transcriptomics and proteomics to define a multi‐phase, extracellular phosphate‐induced, signaling network in pre‐osteoblasts as well as primary human and mouse mesenchymal stromal cells. We identified a rapid mitogenic response stimulated by elevated phosphate that results in the induction of immediate early genes including c‐fos. The mechanism of activation requires FGF receptor signaling followed by stimulation of N‐Ras and activation of AP‐1 and serum response elements. A distinct long‐term response also requires FGF receptor signaling and results in N‐Ras activation and expression of genes and secretion of proteins involved in matrix regulation, calcification, and angiogenesis. The late response is synergistically enhanced by addition of FGF23 peptide. The intermediate phase results in increased oxidative phosphorylation and ATP production and is necessary for the late response providing a functional link between the phases. Collectively, the results define elevated phosphate, as a mitogen and define specific mechanisms by which phosphate stimulates proliferation and matrix regulation. Our approach provides a comprehensive understanding of the cellular response to elevated extracellular phosphate, functionally connecting temporally coordinated signaling, transcriptional, and metabolic events with changes in long‐term cell behavior. J. Cell. Physiol. 228: 1536–1550, 2013.

Temporomandibular Joint Pain and Synovial Fluid Analysis: A Review of the Literature

The pathophysiology of temporomandibular joint pain is not well understood. A significant amount of research has been conducted to evaluate synovial fluid in these patients and in healthy controls. Qualitative and quantitative analyses of the synovial fluid have shown a significant difference between these groups. A multitude of inflammatory mediators and degradation products have been identified. The concentration of these products has been shown to correlate with several clinical parameters including pain, chronicity, severity of degenerative change, and response to treatment. A common inflammatory pathway would appear to be involved in most patients. At the present time, synovial fluid analysis does not have the sensitivity or specificity to allow specific diagnoses and targeted treatment. Continued research with the specific aim of establishing more appropriate therapeutic modalities based on the biochemical pathways is warranted.

Multifocal Traumatic Bone Cysts: Case Report and Current Thoughts on Etiology

p w k m p b a s p l p t a v l u l he traumatic bone cyst was first described by Lucas n 1929 and later defined by Rushton as a single cyst hat has no epithelial lining, has an intact bony wall, is uid filled, and has no evidence of acute or chronic nflammation. The term traumatic bone cyst has been ecognized as a misnomer in that the incidence of rior trauma in patients with this entity is the same as n the general population. A variety of other terms ave been used by different authors to describe the raumatic bone cyst. These include solitary bone yst, simple bone cyst, hemorrhagic bone cyst, rogressive bone cyst, idiopathic bone cyst, and nicameral bone cyst. Overall, more than 95% of hese cases involve the long bones such as the proxmal humerus and femur. Several hypotheses for the athogenesis of this lesion have been postulated. Coen has proposed that the cyst develops because of lack of collateral lymphatic drainage of venous sinuoids. This apparent blockage then results in the enrapment of interstitial fluid causing resorption of the ony trabeculae and cyst development. Alternatively, irra et al proposed that traumatic bone cysts are ynovial cysts, developing as a result of a developmenal anomaly whereby synovial tissue is incorporated ntraosseously. Traumatic bone cysts are typically found as solitary esions. Interestingly, in a review of the literature, muliple synchronous lesions were reported to occur in bout 11% of cases. This case report details an unusual resentation of multiple traumatic bone cysts.

MR Imaging of the Temporomandibular Joint

MR imaging allows detailed evaluation of temporomandibular (TMJ) anatomy because of its inherent tissue contrast and high resolution. Joint biomechanics can be assessed through imaging patients in the closed and open jaw positions. Despite the accuracy of MR imaging in detecting disc position, results must be interpreted together with clinical findings, because an anteriorly displaced disc can be seen in up to one-third of asymptomatic patients, and a normal disc position can be seen in up to one-quarter of symptomatic patients. Interpretation of MR imaging requires knowledge of the normal anatomy and an understanding of normal and abnormal biomechanics.

Use of Opioids in Long-Term Management of Temporomandibular Joint Dysfunction

The long-term treatment of patients with chronic temporomandibular joint dysfunction has been challenging. The long-term use of opioids in these patients can be neither supported nor refuted based on current evidence. However, evidence is available to support the long-term use of opioids in other chronic noncancer pain states with reduced pain, improved function, and improved quality of life. One group of patients with chronic temporomandibular joint pain, for whom both noninvasive and invasive treatment has failed, might benefit from long-term opioid medication. The choices include morphine, fentanyl, oxycodone, tramadol, hydrocodone, and methadone. Adjunct medication, including antidepressant and anticonvulsant drugs, can also be used. The safety of these medications has been well established, but the potential for adverse drug-related behavior does exist, requiring appropriate patient selection, adequate monitoring, and intervention when needed.

What is the Risk of Future Extraction of Asymptomatic Third Molars? A Systematic Review

PURPOSE The purpose of our report was to determine clinically whether young adults who elect to retain their asymptomatic third molars (M3s) have a risk of undergoing 1 or more M3 extractions in the future. MATERIALS AND METHODS To address our clinical question, we designed and implemented a systematic review. The studies included in the present review were prospective, had a sample size of 50 subjects or more with at least 1 asymptomatic M3, and had at least 12 months of follow-up data available. The primary study variables were the follow-up duration (in years) and the number of M3s extracted by the end of the follow-up period or the number of subjects who required at least one M3 extraction. The annual and cumulative incidence rates of M3 removal were estimated. RESULTS Seven studies met the inclusion criteria. The samples sizes ranged from 70 to 821 subjects, and the follow-up period ranged from 1 to 18 years. The mean incidence rate for M3 extraction of previously asymptomatic M3s was 3.0% annually (range 1 to 9%). The cumulative incidence rate for M3 removal ranged from 5% at 1 year to 64% at 18 years. The reasons for extraction were caries, periodontal disease, and other inflammatory conditions. CONCLUSIONS The cumulative risk of M3 extraction for young adults with asymptomatic M3s is sufficiently high to warrant its consideration when reviewing the risks and benefits of M3 retention as a management strategy.

Small and Large Titanium Plates Are Equally Effective for Treating Mandible Fractures

PURPOSE The use of small titanium plates for the management of mandibular fractures continues to be a source of controversy because of their load-sharing properties. The purpose of the present study was to determine whether the use of small plates for mandibular fractures is as efficacious as large plates in a large level I trauma center. MATERIALS AND METHODS Consecutive subjects presenting with mandibular fractures were randomly allocated to the use of either small plates (group 1) or large plates (group 2). The primary predictor variable was the plate size. The primary outcome variable was fracture union. The secondary outcomes included complications and operative time. Statistical analysis was performed using the Wilcoxon rank sum test for ordinal and continuous variables and the χ(2) test or Fisher exact test for proportions. RESULTS A total of 127 consecutive subjects with a fracture of the mandible were enrolled in the study. Of the 127 subjects, 53 completed the required follow-up of at least 6 weeks. There was no difference in the rate of fracture union between the 2 groups (P = .95). CONCLUSIONS The study findings suggest that the use of small plates and monocortical screws for mandibular fractures results in favorable outcomes compared with using larger plates and bicortical screws.

Irrigating drains for severe odontogenic infections do not improve outcome.

PURPOSE The need to irrigate surgical drains in the postoperative period in patients with odontogenic infections is controversial. The purpose of this study was to evaluate the efficacy of irrigating surgical drains postoperatively in patients with severe odontogenic infections. MATERIALS AND METHODS Consecutive patients presenting with severe odontogenic infections who required incision and drainage were randomized to irrigating drains (red rubber catheters) or nonirrigating drains (Penrose drains). The primary predictor variable was the type of drain and the use of postoperative irrigation. The primary outcome variable was length of stay. Secondary outcomes included postoperative temperature, need for additional procedures, and complications. The t test was used for the primary outcome, and a P value lower than .05 was considered statistically significant. RESULTS Forty-six patients completed the study. There was no statistically significant difference in overall length of stay, length of stay after surgery, temperature, or need for additional procedures between the 2 treatment groups. CONCLUSIONS The use of nonirrigating drains appears to be equally efficacious as irrigating drains in the management of severe odontogenic infection.