Joseph E. Cillo

Correlation of inflammatory cytokines with arthroscopic findings in patients with temporomandibular joint internal derangements

PURPOSE The goal of this study was to evaluate the presence of the inflammatory cytokines interleukin-1 beta (IL-1 beta), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-alpha) within the superior temporomandibular joint (TMJ) space in patients with internal derangements and to compare these values with the pathologic findings seen arthroscopically. PATIENTS AND METHODS Thirty patients with symptomatic TMJ dysfunction and clinical and imaging evidence of internal derangements of the TMJ were evaluated. Before entering the superior joint space with the arthroscope, 2 mL sterile saline was injected and, after 30 seconds of equilibration, was aspirated for analysis. The surgeon then performed diagnostic arthroscopy. The degree of synovitis, degeneration, percent condylar roofing, and any pathologic changes, such as perforations, were recorded. The level of total protein in each sample was ascertained, as well as the levels of IL-1 beta, IL-6, and TNF-alpha. RESULTS Of 30 samples tested, three were discarded because of failure to gain access into the superior joint space. Of the 27 remaining samples, IL-6 showed the closest correlation with the level of acute synovitis demonstrated arthroscopically. Two of the higher IL-6 levels (167 and 324 pg/microg protein) were seen with patients with a significant disc perforation. In patients with a high degree of vascularity, IL-6 was found to be between 0 to 581 pg/microg protein with an average of 80 pg/microg protein and a median value of 43 pg/mg. These values significantly correlated with the degree of vascularity (P < or = .02). This is in comparison with the 10 remaining patients, who showed significantly fewer vascular changes arthroscopically. In these patients, the range of IL-6 was 0 to 35 pg/microg protein, with an average of 19 pg/microg protein and a median value of 14.5 pg/microg. These values significantly correlated with the smaller degree of vascularity (P < or = .02). In seven patients, the role of nonsteroidal antiinflammatory drug (NSAID) use resulted in decreased levels of IL-6, which has been noted in previous studies. In patients with higher rated redundancy of the synovial tissue, the average IL-6 level was 92 pg/microg protein, whereas the median value was 44 pg/microg protein. In patients with little or no redundant synovial tissue, an average IL-6 level of 22 pg/microg protein was present. The median value in these same joints was 15 pg/microg protein. These IL-6 values significantly correlated with the degree of redundancy (P < or = .03). The degree of degenerative change (chondromalacia, fibrillation), disc displacement (roofing), and the presence or absence of adhesions did not significantly affect the levels of IL-6 within the patients studied. The presence of IL-1 beta and TNF-alpha was not found to correlate with the arthroscopic findings in the superior joint space. CONCLUSIONS The presence of IL-6 correlated with the degree of acute synovitis. IL-1 beta and TNF-alpha were not found in significant levels within the superior joint space. These findings correlated with those reported by other investigators. The production of IL-6 by synovial cells and its role in TMJ disease warrants further investigation.

Outcome Analysis of Mandibular Condylar Replacements in Tumor and Trauma Reconstruction: A Prospective Analysis of 131 Cases With Long-Term Follow-Up

PURPOSE Replacement of the mandibular condyle with alloplastic materials is sometimes required when the mandibular condyle is involved in pathology or trauma. Previous investigations into alloplastic mandibular condylar replacement have met with mixed results because they reported only a limited number of patients with short-term follow-up. This investigation sought to determine the long-term outcome of alloplastic replacement of the mandibular condyle in a large population of patients after disarticulation due to pathology or trauma. MATERIALS AND METHODS This was a prospective, long-term investigation of 131 consecutive patients who had undergone alloplastic replacement of 132 mandibular condyle(s) for reconstruction after disarticulation for pathology or trauma. Metallic mandibular condylar replacement was carried out using standard principles of rigid fixation after disarticulation with placement of the metallic condylar head against the native condylar disc or a soft tissue interface of either autogenous or allogeneic grafts. Only patients with a minimum of 3-year follow-up were included in this study. Assessment analysis was conducted at 6-month intervals by direct questioning, direct clinical observation, measurements, and radiographic examination. RESULTS A total of 131 consecutive patients underwent 132 mandibular condylar replacements with a metallic condylar head attached to a 2.3- or 2.4-mm reconstruction plate after disarticulation. Follow-up time ranged from 3.4 to 18.6 years with an average of 7.8 years. A total of 13 (9.8%) patients developed minor complications including pain (2/132, 1.5%), loose plate (2/132, 1.5%), limited jaw opening (4/132, 3.0%), and plate exposures all of which were in irradiated patients (6/132, 4.5%). One patient (0.8%) who also was irradiated developed an erosion into the external auditory meatus with pain. None developed an erosion into the middle cranial fossa. CONCLUSIONS Alloplastic replacement of the mandibular condyle with a metallic condyle on a rigid reconstruction plate functioning against a natural disc or a soft tissue graft in the temporal fossa after disarticulation for pathology or trauma provides long-term stability with minimal complications (a total complication incidence of 10.6%).

Relations Between Obstructive Sleep Apnea Syndrome and Specific Cephalometric Measurements, Body Mass Index, and Apnea-Hypopnea Index

PURPOSE To evaluate the relation of specific cephalometric landmarks, body mass index, and the apnea-hypopnea index in patients diagnosed with obstructive sleep apnea syndrome (OSAS) and treated with functional upper airway surgery. MATERIALS AND METHODS This was a retrospective cohort analysis of 89 consecutive patients over a 3-year period diagnosed with overnight-attended polysomnogram-confirmed OSAS who underwent functional upper airway surgery. Five predetermined specific cephalometric parameters were analyzed: posterior airway space, soft palate length, hyoid to mandibular plane angle, sella-nasion to mandibular plane angle, and gonion to gnathion length. Simple and multiple linear regression analyses were used to establish a relation between independent and dependent variables. RESULTS There were no statistically significant associations between the 5 specific cephalometric craniofacial structures in combination with other potential confounders, body mass index and apnea-hypopnea index, and the presence of OSAS. CONCLUSIONS No one skeletal or soft tissue parameter can be directly linked to OSAS.

Pre-Emptive Analgesia With Pregabalin and Celecoxib Decreases Postsurgical Pain Following Maxillomandibular Advancement Surgery: A Randomized Controlled Clinical Trial

PURPOSE The purpose of this study was to determine the efficacy of pre-emptive analgesia with pregabalin and celecoxib on narcotic consumption and perceived pain in adult patients undergoing maxillomandibular advancement surgery for obstructive sleep apnea. PATIENTS AND METHODS This was a prospective, randomized, double-blinded, placebo-controlled study of adult patients undergoing elective maxillomandibular advancement surgery for obstructive sleep apnea. The groups received a masked 1-time preoperative oral dose of pregabalin 150 mg and celecoxib 400 mg (experimental group) or lactose powder 2 g (placebo group). In the postoperative period, pain management consisted of intravenous morphine patient-controlled analgesia and oral oxycodone 5 mg and acetaminophen 325 mg. Patients completed a daily pain and narcotic log. Statistical significance between group means was determined by the 2-tailed independent t test. RESULTS There were statistically significant differences between the pregabalin plus celecoxib and placebo groups in average intravenous morphine consumption per 4-hour interval (6.0 ± 5.9 vs 9.3 ± 7.9 mg; P < .05), mean daily narcotic pill consumption (2.9 ± 2.9 vs 6.8 ± 1.8 pills; P < .05), and mean daily visual analog scale scores (4.3 ± 3.5 vs 5.5 ± 5.0; P < .05). CONCLUSION Within the limitations of this study, a 1-time preoperative oral dose of pregabalin and celecoxib before adult maxillomandibular advancement surgery for obstructive sleep apnea decreased mean intravenous morphine consumption, mean daily narcotic pill consumption, and mean patient perceived pain.

Late Vascular Complication Associated With Panfacial Fractures

embers suggests a sporadic mutation affecting one f the genes responsible for bone homeostasis in this atient. Cranial nerve compression has been described in atients’ with van Buchem disease; however, cerebroascular accidents have not been identified comonly in these patients. Although the patient decribed some disturbance in facial sensation and isplayed skull bone thickening radiographically, it is ifficult to say whether the condition contributed to he cerebrovascular accidents without radiologic evience of compression of the brain or vascular canals n the skull base. Previous reports of surgical intervention on paients with van Buchem disease and ADO have ndicated normal healing although no comments have een made on longer term recurrence at surgicallyddressed sites. We were concerned about the healng capacity of the bone and carried out more limited urgery at the first intervention. These fears seem to e unfounded and, ironically with the wisdom of indsight, the history of palmidronate infusions hould have caused greater concern.

Management of Bilateral Mandibular Angle Fractures With Combined Rigid and Nonrigid Fixation

PURPOSE There is very limited evaluation of the management of fractures of the bilateral mandibular angles. The purpose of this study was to determine the incidence, etiology, and outcomes of bilateral mandibular angle fractures treated with the transoral application of rigid fixation on one side and nonrigid fixation on the other. PATIENTS AND METHODS Patients 18 years of age or older with isolated, noncomminuted fractures through the right and left mandibular angles and treated solely with 2.0-mm miniplates through intraoral incisions (and trocar) were collected from 2 sources. Patients treated at Allegheny General Hospital (Pittsburgh, PA) were prospectively collected from August 1, 2006 through December 31, 2012. Patients treated at Parkland Memorial Hospital (Dallas, TX) and University Hospital in San Antonio (San Antonio, TX) from January 1, 1992 through December 31, 2012 were retrospectively added to the sample. Data collected included age, gender, race, cause of fracture, presence or absence of mandibular third molars, occlusal relation documented at last visit, and occurrence and management of complications. Standard descriptive statistics were used and the relation between initial displacement and adequacy of reduction was evaluated with the Fisher exact test. RESULTS Of 1,565 patients with 2,195 mandibular fractures, 33 (2.1%) presented with bilateral mandibular angle fractures. The average age of the cohort was 25.2 ± 1.8 years (range, 18 to 48 yr). The mechanisms of injury were assaults (30 of 33, 90.9%), motor vehicle collisions (2 of 33, 6%), and a fall (1 of 33, 3%). Twenty-seven patients (81.8%) had at least 1 mandibular third molar at the time of injury. Three patients (9.1%) had minor postoperative wound problems, with 1 incident (3.0%) of malocclusion. There was no statistically significant relation between the initial displacement and the adequacy of reduction. CONCLUSIONS Bilateral mandibular angle fractures are a rare traumatic event that may be successfully treated with transoral rigid and nonrigid fixation with 2.0-mm miniplates.

Analysis of Propofol and Low-Dose Ketamine Admixtures for Adult Outpatient Dentoalveolar Surgery: A Prospective, Randomized, Positive-Controlled Clinical Trial

PURPOSE The purpose of this study was to evaluate the hemodynamic stability and efficacy of 3 different propofol-ketamine admixtures compared with a propofol-saline solution admixture for continuous-infusion intravenous general anesthesia in outpatient adult dentoalveolar surgery. PATIENTS AND METHODS This was a prospective, randomized, positive-controlled clinical trial between a propofol-saline solution admixture and 3 propofol-ketamine admixtures comprising 4 groups: group A (control), propofol and saline solution; group B, 10:1 propofol-ketamine ratio; group C, 5:1 propofol-ketamine ratio; and group D, 3:1 propofol-ketamine ratio. The bispectral index (BIS) was used to monitor all patients for time to induction (BIS <70) to recovery time (BIS >90). The outcome variables-noninvasive systolic, diastolic, and mean blood pressures; pulse; and BIS-were recorded at baseline and every 5 minutes during surgery. One-way analysis of variance and χ(2) analysis were conducted on the groups to determine statistical significance, set at P < .05. Post hoc pair-wise comparisons with Bonferroni adjustments were conducted on statistically significant groups. RESULTS A total of 64 adult patients (37 men and 27 women; mean age, 27.3 years) who had dentoalveolar surgery under intravenous general anesthesia in an outpatient oral and maxillofacial surgery clinic setting were enrolled in this study. There were statistically significant differences between mean values of groups only for mean systolic blood pressure and mean blood pressure in groups A and D (127 mm Hg vs 146 mm Hg and 96 mm Hg vs 109 mm Hg, respectively). There were statistically significant differences in percent change from baseline measurements only between groups A and D for systolic blood pressure (-6.9% vs +1.3%), diastolic blood pressure (-5.4% vs +0.7), and mean arterial pressure (-0.5% vs +2.6%). All mean percent changes from baseline were within 20% of baseline. There were statistically significant differences between groups for number of boluses but not time to surgery start, movement on injection, or length of surgery. Statistically significant differences in recovery times were found between all groups except between groups A and C and groups C and D. There were no incidences of postoperative nausea or vomiting in the immediate postoperative period. CONCLUSIONS Through maintenance of hemodynamic stability and faster recovery time, the group B admixture (10:1 propofol-ketamine ratio) provided the greatest benefit for continuous intravenous general anesthesia in adults undergoing dentoalveolar surgery in an outpatient clinic setting.

The Tent Pole Splint: A Bone-Supported Stereolithographic Surgical Splint for the Soft Tissue Matrix Expansion Graft Procedure

This report details the use of computer-aided planning and intraoperative stereolithographic direct-bone-contact surgical splints for the accurate extraoral placement of dental implants in the soft tissue matrix expansion (tent pole) graft of the severely resorbed mandible.

Combined Elliptical Window Genioglossus Advancement, Hyoid Bone Suspension, and Uvulopalatopharyngoplasty Decrease Apnea Hypopnea Index and Subjective Daytime Sleepiness in Obstructive Sleep Apnea

PURPOSE The objective and subjective outcomes of combined mandibular elliptical window genioglossus advancement, hyoid bone suspension, and uvulopalatopharyngoplasty procedures have not been evaluated. This study was conducted to evaluate postoperative changes in the apnea hypopnea index (AHI) and subjective daytime sleepiness with this combination of procedures in the surgical management of obstructive sleep apnea (OSA). PATIENTS AND METHODS This was a retrospective cohort analysis of patients who had undergone combined elliptical window genioglossus advancement, hyoid bone suspension, and uvulopalatopharyngoplasty performed at Allegheny General Hospital (Pittsburgh, PA) from July 1, 2006 through December 31, 2008 for polysomnogram-confirmed OSA. Inclusion criteria included patients who had undergone the combined elliptical window genioglossus advancement, hyoid bone suspension, and uvulopalatopharyngoplasty procedures with preoperative and minimum 6-month postoperative AHI and Epworth Sleepiness Scale (ESS). Statistical significance between mean differences of pre- and postoperative AHI and ESS was determined with the 2-tailed paired t test and 95% confidence intervals. RESULTS Thirteen male patients (average age, 43.0 ± 2.4 yr; average follow-up, 18.0 ± 3.6 months) were included in this study. There were statistically significant differences between mean pre- and postoperative AHI (28.3 vs 12.1; P < .05; mean change, -16.2; 57.2% decrease) and ESS (15.2 vs 6.3; P < .05; mean change, -8.9; 58.6% decrease). CONCLUSION The combined mandibular elliptical window genioglossus advancement, hyoid bone suspension, and uvulopalatopharyngoplasty procedures for the treatment of OSA decrease AHI and subjective daytime sleepiness.

Proceedings of the American Association of Oral and Maxillofacial Surgeons 2015 Research Summit

The Fifth Biennial Research Summit of the American Association of Oral and Maxillofacial Surgeons and its Committee on Research Planning and Technology Assessment was held in Rosemont, Illinois on May 6 and 7, 2015. The goal of the symposium is to provide a forum for the most recent clinical and scientific advances to be brought to the specialty. The proceedings of the events of that summit are presented in this report.