Kasey K. Li

The odontogenic keratocyst : A 20-year clinicopathologic review

The odontogenic keratocyst (OKC) is a jaw cyst with a proclivity for local invasion and recurrence. This 20‐year retrospective study was conducted to evaluate methods of treatment and recurrence rates. Forty‐nine patients were identified with an average age at presentation of 39.5 years. The molar region of either the mandible or maxilla was the principal primary location; the maxillary antrum was also a common site. The majority of cysts were unilocular and associated with adjacent dentition. Initial therapy was typically enucleation with or without extraction of associated teeth; seven cases of recurrent or second primary odontogenic keratocysts required more extensive surgery. Follow‐up ranged from 1 to 15 years with an average duration of 4.3 years. The overall recurrence rate was 35%, and the average time to recurrence 4 years. A recurrence rate of 60% was documented for patients with basal cell nevus syndrome or a family history thereof. Long‐term follow‐up is necessary following initial OKC treatment. The high rate of recurrence in patients with documented or suspected basal cell nevus syndrome suggests the need for more aggressive initial surgical management in this selected patient population.

Location of the descending palatine artery in relation to the Le Fort I osteotomy

PURPOSEnThis study evaluated the positional relationship of the descending palatine artery to the Le Fort I osteotomy.nnnMATERIALS AND METHODSnThree separate examinations were performed. In the first, 30 human skulls were used, and measurements were made of the greater palatine canal and foramen in relation to maxillary landmarks pertaining to the Le Fort I osteotomy. In the second, 40 patients with normal or minimal sinus mucosal thickening were selected from a pool of patients who underwent computed tomography (CT) scanning for sinus evaluation. These patients were scanned on a Somatome Plus spiral CT scanner as part of a routine sinus protocol, with the addition of an axial image 3 mm above the nasal floor where the Le Fort I osteotomy is usually performed. The distance from the greater palatine canal to the piriform rim was measured. In the third, eight fresh cadavers were used, and the distance from the internal maxillary artery to the nasal floor was measured.nnnRESULTSnThe internal maxillary artery enters the pterygopalatine fossa approximately 16.6 mm above the nasal floor and gives off the descending palatine artery. The descending palatine artery travels a short distance within the pterygopalatine fossa and then enters the greater palatine canal. It travels approximately 10 mm within the canal in an inferior, anterior, and slightly medial direction to exit the greater palatine foramen in the region of the second and third molars.nnnCONCLUSIONnInjury to the descending palatine artery during Le Fort I osteotomy can be minimized by not extending the osteotomy more than 30 mm posterior to the piriform rim in females. This distance can be extended to 35 mm in males. Pterygomaxillary separation should be made by closely adapting the cutting edge of a curved osteotome or right-angled saw to the pterygomaxillary fissure while avoiding excessive anterior angulation. Furthermore, the superior cutting edge of the osteotome or saw blade should be less than 10 mm above the nasal floor.

Anatomic location of the tongue base neurovascular bundle

Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. Transoral and transcervical resections of the tongue base may be performed with greater exposure and certainty when the relationship of the HLNVB to local landmarks is understood; knowledge of the HLNVB allows resection of a larger amount of contralateral tongue base during partial glossectomy without violating the contralateral remnant tongues blood supply. Ten cadaver heads were dissected to determine the position of the HLNVB with respect to soft tissue and bony landmarks at the tongue base. Our results indicate the position of the tongue base HLNVB is significantly inferior and lateral, that is, 2.7 cm inferior and 1.6 cm lateral to the foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromise.

Reconstruction of the severely atrophic edentulous maxilla using Le Fort I osteotomy with simultaneous bone graft and implant placement

PURPOSEnThis study evaluated the outcome of patients who underwent simultaneous Le Fort I osteotomy, an interpositional bone graft, and implant placement for reconstruction of the severely atrophic edentulous maxilla.nnnPATIENTS AND METHODSnTwenty patients operated by the same surgeon were included in the study. Patients were followed annually with clinical and radiographic examinations for an average of 33 months.nnnRESULTSnOne hundred thirty-nine implants were initially inserted in the bone grafts at the time of Le Fort I osteotomy. Twenty-five implants (18%) failed to osseointegrate. Seventeen of the 25 implants lost were from three patients. The most significant prognostic factor appeared to be the thickness of the atrophic maxillary ridge. Twelve of the 20 patients completed prosthetic restoration, with an average follow-up of 21 months after loading. No implants were lost after loading, and all prostheses have remained stable.nnnCONCLUSIONSnThis method of reconstruction of the severely atrophic maxilla achieves an implant survival rate of 82% while correcting the unfavorable maxillomandibular relationship commonly seen in these patients.

Traumatic optic neuropathy: Result in 45 consecutive surgically treated patients

The management of traumatic optic neuropathy remains controversial. In this report, we present the results of 45 patients treated with extracranial optic nerve decompression after at least 12 to 24 hours of corticosteroid therapy without improvement. Vision improved in 32 patients after surgery (71%), and the mean percentage of improvement from preoperative visual deficit was 40.7% ± 6.9% (median improvement 41.2%). Worsening of vision occurred in none of the patients as a result of the surgery, and no intraoperative or postoperative complications were encountered. We present a treatment protocol for traumatic optic neuropathy with the use of megadose corticosteroids and optic nerve decompression.

Reversal of blindness after facial fracture repair by prompt optic nerve decompression

Blindness associated with facial fracture repair is a devastating complication. Fortunately, its occurrence is rare. Orbital compartment syndrome resulting from retrobulbar hemorrhage is the leading cause of visual compromise after facial trauma surgery, with a reported incidence of 0.3% after zygomatic fracture repair.’ Other factors that may contribute to visual loss include direct intraoperative injury to the optic nerve from surgical manipulation, bony fragments, orbital implants, or inferior retinal arteriolar occlusion associated with postoperative orbital swelling.2,3 cial fracture repair in which the vision was salvaged by orbital and optic nerve decompression. Possible contributing factors to the postoperative blindness are discussed.

Descending necrotizing mediastinitis: a complication of dental implant surgery.

The placement of osseointegrated dental implants is considered a minimally invasive procedure with a low complication rate. Reported complications include local trauma to neurovascular structures, mandible fractures, sinusitis, and localized gingivitis. Major life‐threatening complications are extremely rare. Severe infection has not been reported in a review of the English literature.

Acanthamoeba rhinosinusitis: characterization, diagnosis, and treatment.

Nasal and paranasal sinus manifestations are among the most common presentations of the acquired immunodeficiency syndrome (AIDS). Several studies cite that as many as 70% of patients with this disease have symptoms referable to the head and neck, including a 30% prevalence of sinusitis. Although the bacteriology of sinusitis in this population is largely considered comparable to that of immunocompetent patients, several opportunistic pathogens have been identified, particularly when T-cell counts are low. This report identifies Acanthamoeba as a potentially fatal cause of rhinosinusitis in immunosuppressed patients. The pathogenesis, diagnosis. and treatment of this rare entity will be discussed and the literature reviewed.

Extracranial optic nerve decompression: a 10-year review of 92 patients.

Over a 10-year period the authors have performed 92 transethmoidal optic nerve decompressions for the treatment of visual loss due to various pathological processes, including 45 cases of trauma, 32 cases of neoplasm, 2 cases of bacterial pansinusitis, 5 cases of sphenoethmoidal mucocele, 4 cases of aspergillosis (all were immunocompetent patients), 2 cases of Wegeners granulomatosis, and 2 cases of sarcoidosis. Forty-eight patients (52%) had preoperative visual acuity of light perception or better, and in 44 patients (48%) the preoperative vision was no light perception. Sixty-five patients (71%) achieved improvement of vision postoperatively. Twenty-four patients (26%) had no change in vision and 3 patients (3%) had deterioration of vision after surgery. The mean percentage of improvement was 40.7% +/- 6.9% in the trauma group, 61.6% +/- 23.2% in the neoplasm group, 66.4% +/- 25.2% in the infectious/mucocele group, and only one patient in the inflammatory group had slight visual improvement from no light perception to counting fingers. Extracranial optic nerve decompression can result in the improvement of visual function in some patients with optic nerve injury from various causes.

The importance of mandibular position in microvascular mandibular reconstruction.

The challenge of mandibular reconstruction rests in the difficulty of re‐creating the intricate three‐dimensional relationship of the oral cavity, thereby ensuring occlusal relationships, oral competence, and facial contour. Recent advances in microvascular surgery have made reliable transfer of autologous tissue possible, but successful reconstruction depends on accurate insetting of the bone flap.