Jyrki Törnwall

Novel maxillary reconstruction with ectopic bone formation by GMP adipose stem cells

Microvascular reconstruction is the state-of-the-art in many fields of defect surgery today. Currently, reconstruction of large bony defects involves harvesting of autologous bone causing donor site morbidity and risk of infection. Specifically, utilizing autologous adipose stem cells (autoASCs), large quantities of cells can be retrieved for cell therapy applications and the risk of tissue rejection is diminished. The authors describe the first case report of a microvascular custom-made ectopic bone flap employing good manufacturing practice (GMP) level ASCs. The patient underwent a hemimaxillectomy due to a large keratocyst. After 36 months of follow-up, the defect was reconstructed with a microvascular flap using autoASCs, beta-tricalcium phosphate and bone morphogenetic protein-2. ASCs were isolated and expanded in clean room facilities according to GMP standards and were characterized in vitro. After 8 months of follow-up, the flap had developed mature bone structures and vasculature and was transplanted into the defect area. Postoperative healing has been uneventful, and further rehabilitation with dental implants has been started. The in vitro characterization demonstrated multipotentiality and mesenchymal stem cell characteristics in ASCs. This is the first clinical case where ectopic bone was produced using autoASCs in microvascular reconstruction surgery and it will pave way for new clinical trials in the field.

CURRENT ISSUES IN THE DIAGNOSIS AND TREATMENT OF SJOGREN'S SYNDROME

Modification of the European Cooperative Group (EEC) criteria for Sjögrens Syndrome (SS) should lead to less confusion in diagnosis and therapeutic trials. The proposed EEC modification will require either a positive minor salivary gland biopsy or a positive autoantibody against Sjögrens-associated A (Ro) or B (La) antigen. This modification will decrease the proportion of women fulfilling EEC criteria from 3-5% to about 0.5%, which is similar to San Diego and San Francisco criteria. Genetic studies have shown increased frequency of alleles for peptide transporter genes TAP1 (0101) and TAP2 (0101) genes as well as tumor necrosis factor microsatellite a2 alleles. Although these markers confer markedly increased risk, they are found in only a small proportion of patients. An increased frequency of drug (antibiotic) allergy and other allergic manifestations appears present in patients with SS and may be linked to HLA-DR3. Hepatitis C as a cause of sicca symptoms, positive anti-nuclear autoantibodies, and mixed cryoglobulinemia is increasingly reported in different parts of the world. Antibodies against muscarinic M3 receptor and expression of costimulatory molecules (CD80 and CD86) by ductal epithelial cells may play a role in pathogenesis. Treatment with pilocarpine is effective in double-blind trials and low dose oral alpha interferon looks promising in initial open studies. In pregnant patients who exhibit evidence of neonatal heart block, treatment with dexamethasone is preferred over prednisone, since the placenta is unable to metabolically activate the latter compound.

Neuropeptides in Experimental and Degenerative Arthritis

Abstract: Classical symptoms of both inflammatory and degenerative arthritides may contribute to neurogenic responses like wheal, flare, edema, and pain. Rheumatoid arthritis (RA) is an autoimmune disease with an immunogenetic background. Neurogenic inflammation has been considered to play an essential role in RA, in part because of the symmetrical involvement (cross‐spinal reflexes) and the predominant involvement of the most heavily innervated small joints of the hands and the feet (highly represented in the hominiculus). In contrast, osteoarthritis (OA) is considered to arise as a result of degeneration of the hyaline articular cartilage, which secondarily results in local inflammation and pain. However, it is possible that the age‐related and predominant (compared to nociceptive nerves) degeneration of the proprioceptive, kinesthetic and vasoregulatory nerves can represent the primary pathogenic events. This leads to progressive damage of tissue with extremely poor capacity for self‐regeneration. Inflammation, be it primary/autoimmune or secondary/degenerative, leads to peripheral sensitization and stimulation, which may further lead to central sensitization, neurogenic amplification of the inflammatory responses and activation of the neuro‐endocrine axis. Neuropeptides serve as messengers, which modulate and mediate the actions in these cascades. Accordingly, many neuropeptides have been used successfully as experimental treatments, most recently VIP, which effectively controlled collagen‐induced arthritis in mice. Therefore, it can safely be concluded that better treatment/control of disease activity and pain can be achieved by blocking the cascade leading to initiation and/or amplification of inflammatory process combined with effects on central nociceptive and neuroendocrine responses.

Occurrence and Types of Associated Injuries in Patients With Fractures of the Facial Bones

PURPOSE To identify the occurrence, types, and severity of associated injuries outside the facial region among patients diagnosed with facial fractures, and to analyze whether there are any factors related to associated injuries. MATERIALS AND METHODS This was a cross-sectional study of 401 patients diagnosed with facial fractures during the 2-year period from 2003 to 2004. RESULTS Associated injuries were observed in 101 patients (25.2%). The most common type of injury was a limb injury (13.5%), followed by brain (11.0%), chest (5.5%), spine (2.7%), and abdominal (0.8%) injuries. Multiple associated injuries were observed in 10% and polytrauma in 7.5%. The mortality rate was 0.2%. The occurrence of associated injury correlated significantly with trauma mechanism and fracture type; high-speed accidents and severe facial fractures were significant predictors of associated injury. CONCLUSIONS Associated injuries are frequent among patients who have sustained facial fractures. The results underscore the importance of multiprofessional collaboration in diagnosis and sequencing of treatment, but also the importance of arranging appropriate clinical rotations for maxillofacial residents in training.

Sentinel lymph node mapping using SPECT–CT fusion imaging in patients with oral cavity squamous cell carcinoma

Lymphoscintigraphic planar imaging is commonly performed to locate the sentinel lymph nodes (SLN) preoperatively. The images are, however, obscure lacking anatomical information and only rough topographical orientation of the SLNs is possible. Image fusion of Single Photon Emission Computed Tomography (SPECT) and Computed Tomography (CT) has been suggested to be an anatomically more precise method for preoperative SLN mapping. In the present study, preoperative lymphoscintigraphic SLN mapping was performed by using a hybrid gamma-camera with CT system (SPECT–CT) in addition to conventional planar lymphoscintigraphy in 15 consecutive patients with squamous cell carcinoma (SCC) of the oral cavity. The planar images were compared to fused SPECT and CT images. SPECT–CT fusion images showed only one SLN that was not detected in planar images. Two SLNs suspected in planar images could be excluded by SPECT–CT. The location of the SLNs could be determined more accurately by SPECT–CT. SPECT–CT fusion imaging was found feasible for preoperative SLN identification in patients with oral cavity SCC. It enables more accurate localisation of the SLNs, but it rarely reveals SLNs, that are not detected on planar images.

Neuropeptides of the autonomic nervous system in Sjögren’s syndrome

OBJECTIVE To assess the activity level of the autonomic nervous system in Sjögren’s syndrome (SS) and to correlate this with stress. METHODS Patients with SS (n=12) and healthy controls (n=10) were analysed for the content of vasoactive intestinal peptide (VIP) and neuropeptide Y (NPY) in their stimulated saliva by radioimmunoassays and for stress by the use of a modified Jenkins Activity Survey (JAS). RESULTS The data are expressed as median (interquartile range). Salivary VIP output (pg/min) and NPY output (pg/min) were high in SS compared with healthy controls (30.0 (15.6, 36.6) versus 12.3 (9.2, 24.0), p=0.045, 4.8 (0.6, 24.1) versus 0.7 (0.0, 2.4), p=0.038, respectively). Patients experienced only a little, but not significantly, more stress than the healthy controls (stress index −2.8 (−7.7, 6.9) versus −5.2 (−12.9, 2.7), p>0.05). Stress in general was associated with high salivary VIP concentrations (r=0.41, p=0.05). CONCLUSIONS These findings show that adequately processed saliva (containing aprotinin and EDTA as neuropeptidase inhibitors) contains measurable amounts of marker peptides of the autonomic nervous system. Secondly, VIP concentration but not output may be affected by stress, which may act by decreasing watery salivary flow. In patients with SS, VIP and NPY outputs are increased. This may indicate increased leakage into saliva or efforts to compensate for the diminished salivary flow, or both.

Changing trends in causes and patterns of facial fractures in children

OBJECTIVE To review the epidemiology of facial fractures in children and to analyze whether it has changed over time. STUDY DESIGN Retrospective review of records of children aged < or = 15 years diagnosed for fracture during 2 10-year periods. RESULTS A total of 378 children were diagnosed with fractures, 187 in 1980-1989 and 191 in 1993-2002. The proportion of children with mandibular fractures decreased by 13.6 percentage-points from the first period to the second, whereas the proportion of patients with midfacial fractures increased by 18.7 percentage-points. Assault as a causative factor increased by 5.5 percentage-points, almost exclusively among children aged 13-15 years, with a high percentage (23.5%). CONCLUSIONS Recognition of a change in fracture patterns over time is probably due to the increased use of computerized tomographic scanning.

Bisphosphonate treatment in craniofacial fibrous dysplasia—a case report and review of the literature

Fibrous dysplasia (FD) is a benign skeletal disorder which may affect one or multiple bones. Lesions often involve long bones, ribs, and craniofacial bones and cause pain, fractures, and disfigurement. We describe an adolescent girl with mandibular FD who was successfully treated with bisphosphonates. She presented with a tumor-like lesion of the mandible. During the 2-year follow-up, the lesion expanded and caused significant disfigurement and pain necessitating psychiatric support. Treatment with bisphosphonate administered intravenously resulted in rapid pain relief, normalization of bone turnover, and cosmetic improvement. Management of FD has previously consisted of either conservative follow-up or surgery depending on disease activity and localization. Based on published reports and our experience, bisphosphonates should be considered in the treatment of symptomatic cases. This line of treatment may be suitable especially for craniofacial FD in which surgical treatment is particularly challenging.

Does Perioperative Glucocorticosteroid Treatment Correlate With Disturbance in Surgical Wound Healing After Treatment of Facial Fractures? A Retrospective Study

PURPOSE To clarify whether perioperative glucocorticosteroid treatment used in association with repair of facial fractures predisposes to disturbance in surgical wound healing (DSWH). PATIENTS AND METHODS Retrospective review of records of patients who had undergone open reduction, with or without ostheosynthesis, or had received reconstruction of orbital wall fractures during the 2-year period from 2003 to 2004. RESULTS Steroids were administered to 100 patients (35.7%) out of a total of 280. Dexamethasone was most often used, with the most common regimen being dexamethasone 10 mg every 8 hours over 16 hours, with a total dose of 30 mg. The overall DSWH rate was 3.9%. The DSWH rate for patients who had received perioperative steroids was 6.0%, and the corresponding rate for patients who did not receive steroids was 2.8%. The difference was not statistically significant. An intraoral surgical approach remained the only significant predictor to DSWH. CONCLUSIONS With regard to DSWH, patients undergoing operative treatment of facial fractures can safely be administered doses of 30 mg or less of perioperative glucocorticosteroids equivalent to dexamethasone.

Occurrence and types of dental injuries among patients with maxillofacial fractures

The aim of this retrospective study was to clarify the occurrence and types of dental injuries in 389 patients who had been diagnosed with facial fractures, and to analyze whether the occurrence of dental injury correlates to gender, age, trauma mechanism and type of facial fracture. Dental injuries were observed in 62 patients (16%). The most common type of injury was a crown fracture (48%). Dental injuries were multiple in most patients (63%). Almost half (48%) of all injured teeth were severely injured. Most injured teeth (61%) were in the maxilla. The incisor region was the most prevalent site in both the mandible (45%) and the maxilla (56%). The occurrence of dental injury correlated significantly with trauma mechanism and fracture type: motor vehicle accidents and mandibular fracture were significant predictors for dental trauma. The notable rate of dental injury observed in the present study emphasizes the importance of a thorough examination of the oral cavity in all patients who have sustained facial fracture. Referral to a dental practice for further treatment and follow up as soon as possible after discharge from hospital is fundamental.