Kittipong Dhanuthai

Management of odontogenic keratocysts of the jaws: A ten-year experience with 120 consecutive lesions

BACKGROUND The treatment of odontogenic keratocyst (OKC) of the jaws remains controversial. The aim of this study was to report the outcome of our conservative treatment protocol for OKC. METHODS We collected data of all OKC patients treated in the Department of Maxillofacial Surgery, Pitié-Salpêtrière University Hospital from 1995 to 2004. Basal cell naevus syndrome (Gorlins syndrome) patients were excluded. Recurrence data was analysed in relation to radiographic features, type of microscopic diagnosis, presence of cortical perforation, and site of involvement. RESULTS One hundred and twenty cysts in 109 patients were examined. OKCs were more frequent in the third and the fourth decades of life (range: 11-79 years, mean: 40 years) and in men (n=71). Most of the lesions were unilocular radiolucencies in the tooth-bearing area and in the posterior part of the mandible. Histologically, 80 lesions showed parakeratosis. Most of the patients underwent uneventful enucleation. Postoperatively, infection occurred in 4 patients, and there was no jaw fracture. Recurrence was found in 28 cysts (26%), of which 7 cysts (6%) had multiple recurrences. There was no significant association between recurrences and radiographic features, histological type, cortical perforation, or site of involvement (P>0.05). Recurrences were common in the first 5 years after the operation. The average follow-up was 86 months since the last operation (range: 18-151 months). CONCLUSIONS Despite the retrospective nature, no control group and a relatively high recurrence rate, our study suggests that enucleation with the aid of computed tomography and adequate postoperative surveillance is a conservative treatment which yields clinically acceptable results. However, the patients must strictly adhere to close follow-ups because recurrences may have serious consequences. Our algorithm for managing OKCs and cyst-like lesions of the jaws is also presented.

Management of osteoradionecrosis of the jaws: An analysis of evidence

AIM To review and discuss the management of jaw bone osteoradionecrosis (JORN) based on levels of evidence. METHODS The Medline/PUBMED and Cochrane search was performed to identify all studies on the management of JORN, published in English, French, and German during January 1975-October 2007. Only clinical researches were identified and classified into four levels of evidence before being examined. All references of the retrieved articles were analysed. FINDINGS Seventy three articles and their additional 45 citations were evaluated. Most of the eligible literature provided observational evidence. Hyperbaric oxygen therapy (HBOT) is an adjunct; however, its clinical usefulness remains controversial. A conservative approach should be limited to early-onset JORN, while radical surgery is indicated for an advanced or refractory lesion. Free tissue transfer is the reconstruction of choice for large defects without the need of HBOT. Some new technologies have also been studied, including ultrasound, biological molecules, distraction osteogenesis and antioxidant agents. CONCLUSIONS Most of the reports on the treatment of JORN offer weak evidence. Current information seems insufficient for establishing the definite treatment guideline; thus, well-designed studies with long-term clinical data are encouraged.

Publication bias in oral and maxillofacial surgery journals: An observation on published controlled trials

BACKGROUND Publication bias (PB) diminishes the full distribution of research, distorts and discredits the scientific record, and thus compromises evidence-based practice. The objective of this study was to analyse published controlled trials with regard to PB in leading oral and maxillofacial surgery (OMS) journals. METHODS All controlled trials published in the International Journal of Oral and Maxillofacial Surgery, Journal of Cranio-Maxillofacial Surgery, Journal of Oral and Maxillofacial Surgery, and British Journal of Oral and Maxillofacial Surgery in 2008 were analysed for a primary outcome, country of authors, sample size, gender of the first author, funding source and location of the study. RESULTS Of 952 published articles, 53 controlled trials (5.7%) were identified. The OMS journals preferentially published controlled trials with a positive outcome (77.4%) and from high-income countries (73.6%). Single-centred trials (86.8%) with low sample size (n<100; 69.8%) were published more frequently. The majority of the first authors were male (75.5%). Funding source disclosure was missing in most studies (73.6%) [corrected]. CONCLUSIONS Our results suggest the possible existence of PB in the OMS literature. Hence, it should be borne in mind that the published articles may not be representative of all scientific works, especially when systematic reviews and meta-analyses are conducted or read. In the meantime, journals should establish measures to eliminate PB to uphold scientific integrity. However, this study was an observation based on the published articles. An analysis of all submitted manuscripts would provide more accurate estimates of PB. Ethical considerations on PB are also discussed.

Postoperative complications of fibular free flaps in mandibular reconstruction: an analysis of 25 consecutive cases

OBJECTIVE The objective of this study was to analyze complications following fibular free flap (FFF) transfer for mandibular reconstruction using our definition of postoperative complications. STUDY DESIGN Retrospective observational study. PATIENTS AND METHODS This retrospective study presents our 4-year experiences with FFF for mandibular reconstruction by a single microsurgical team. Data were collected through patient record review and clinical evaluation by 2 independent assessors. We defined complications as any unwanted postoperative outcomes that compromised patient care. Early complication occurred within the first 2 weeks postoperatively; late complications occurred afterward. RESULTS Of 25 patients included, 13 patients (56%) experienced complications. Early and late complications occurred in 13 and 9 patients, respectively. These included flap loss, malunion, skin-paddle necrosis, orocutaneous fistula, wound dehiscence, hematoma, soft tissue contracture, intraoral hair growth, facial asymmetry, osteoradionecrosis, donor-site morbidity, and medical complications. Revision surgeries were performed in 10 patients, ranging from wound dressing to flap removal. All but 2 flaps survived, yielding an overall success rate of 92%. Most of the patients were alive without disease (92%) at the end of the study. Average follow-up was 47.2 months (range: 26-77). CONCLUSION Despite the small number of patients, these preliminary data suggest a relatively high frequency of complications following the FFF reconstruction based on our definition. Minor complications are common and should not be neglected because they may lead to devastating consequences. This should also be a part of informed consent for patients. Complications after the FFF transfer await keen evaluation to establish guidelines to improve end results.

A treatment algorithm for managing giant mandibular ameloblastoma: 5-year experiences in a Paris university hospital

AIMS To review our experiences with giant mandibular ameloblastoma (GMA) over a 5-year period, and to formulate a treatment algorithm for managing this tumour. METHODS We retrospectively reviewed all GMA patients who underwent segmental mandibulectomy and immediate free fibular osteoseptocutaneous flap reconstruction (SM-IFFOFR) by a single reconstructive team from 2002 to 2006. All treatment methods and outcomes were analysed. FINDINGS Forty-four ameloblastoma patients were operated upon during this study period. Sixteen cases had GMA, of which 9 patients were included in this series (mean age: 35 years). The defects in the mandible ranged from 7 to 16 cm in length (mean: 12 cm). The average length of the harvested fibula was 11 cm, and the number of osteotomies ranged from 1 to 2. The mean ischemic time was 137 min (range: 90-180 min). Neck recipient vessels were used for flap perfusion in all cases. All but one flaps were viable without any complications, whilst partial skin-island necrosis occurred in 2 patients. Hospital stay was 2 weeks in most of the patients. No tumour recurrence was found during the follow-up period (range: 26-73 months). Dental implants were placed in 2 patients. CONCLUSIONS Despite several limitations of this study, we suggest that a radical approach with the SM-IFFOFR is an effective treatment for GMA. Further well-designed, larger series with longer follow-up periods are still encouraged.

Ameloblastoma: a multicentric study

OBJECTIVE The objective of this study was to supplement the current ameloblastoma database by reporting the clinicopathologic features of ameloblastoma from Asia and North America. MATERIALS AND METHODS Biopsy records of the participating institutes were reviewed for lesions diagnosed as ameloblastoma during the years 1993 to 2009. Slides were reclassified according to the World Health Organization Classification of Odontogenic Tumors in 2005. Clinical information and radiographic features were collected and analyzed. RESULTS The mean age of the patients ± SD was 38.27 ± 17.78 years; 662 patients (51.36%) were men. Mandible (84.26%) outnumbered maxilla and other locations combined in all countries. The number of multilocular radiolucencies (43.40%) was comparable with that of unilocular radiolucencies (42.04%). Follicular pattern was the most common histopathologic pattern (27.70%), followed by plexiform (21.10%) and unicystic pattern (20.71%), respectively. CONCLUSIONS The clinicopathologic features of ameloblastomas in the present study show some similarities with previous studies; however, minor differences exist.

Expression of IFN-γ before and after treatment of oral lichen planus with 0.1% fluocinolone acetonide in orabase

BACKGROUND Oral lichen planus (OLP) is a common chronic inflammatory mucosal disease in which T-cell-mediated immune responses are implicated in the pathogenesis. The purpose of this study was to investigate the effect of 0.1% fluocinolone acetonide in orabase (FAO) on the in situ expression of IFN-gamma in patients with OLP. METHODS Twenty OLP patients were enrolled in this study. Biopsy specimens and serum samples were obtained before and 1-month after the treatment with 0.1% FAO. In situ expression and serum levels of IFN-gamma were determined using immunohistochemistry and ELISA, respectively. RESULTS The number of IFN-gamma-positive mononuclear cells in OLP lesions before the treatment was significantly higher as compared with that after the treatment. Similarly, the mean number of total mononuclear cells was clearly decreased after the treatment. However, the serum levels of IFN-gamma were not detectable. CONCLUSIONS Our results suggest that IFN-gamma expression in OLP tissue may involve in the immunopathogenesis and the treatment with 0.1% FAO had an immunomodulating effect on the decrease of IFN-gamma.

Ethical issues in instructions to authors of journals in oral-craniomaxillofacial/ facial plastic surgery and related specialities

BACKGROUND Ethical standards of biomedical publications are associated with editorial leadership, such as contents of instructions to authors and journals mechanisms for research and publication ethics. OBJECTIVES To compare ethical issues in the guidelines for authors in oral-craniomaxillofacial/facial plastic surgery (OCM-FPS) journals with those in plastic surgery and otorhinolaryngology/head and neck surgery (ORL-HNS) journals, and to evaluate the relationship between journals impact factor (IF) and ethical issues in the instructions to authors. METHODS This study used a cross-sectional study design. The predictor variables were journals specialty and IF. The outcome variable was the presence of seven ethical issues in the online versions of journals instructions to authors in October 2009. We included only journals with identifiable IF for 2008, published in English, French, German and Thai. Appropriate descriptive and univariate statistics were computed for all study variables. The level of statistical significance was set at P<0.05. RESULTS The sample was composed of 48 journals: seven OCM-FPS (14.6%), 14 plastic surgery (29.2%) and 27 ORL-HNS (56.2%) journals. Only four journals (8.3%) mentioned all ethical issues in their guidelines for authors. Neither journals specialty nor IF was linked to completeness of the ethical requirements. CONCLUSIONS The results of this study suggest that ethical issues in the instructions to authors of most IF-indexed journals in OCM-FPS, plastic surgery and ORL-HNS are incomplete, regardless of specialty and IF. There is room for substantial improvement to uphold scientific integrity of these surgical specialties.

Head and neck lesions of Kimura's disease: Exclusion of human herpesvirus-8 and Epstein-Barr virus by in situ hybridisation and polymerase chain reaction. An immunohistochemical study *

INTRODUCTION Kimuras disease (KD) is a chronic inflammatory disorder, characterised by tumour-like lesions in the head and neck region, producing salivary gland nodules and lymph node enlargement. Many authors suggest that KD is a reactive immunological disorder; however, its aetiology remains unknown. AIMS To study immunohistochemical characteristics of head and neck lesions of KD (H&N-KD) and to investigate the possible role of human herpesvirus-8 (HHV-8) and Epstein-Barr virus (EBV) in the development of H&N-KD. PATIENTS AND METHODS This study enrolled five H&N-KD specimens from three patients treated between 1995 and 2005 at Pitié-Salpêtrière University Hospital, Paris, France. Immunohistochemical studies were performed on formalin-fixed, paraffin-embedded tissue. HHV-8 DNA was determined by polymerase chain reaction (PCR) analysis, whilst EBV sequences were identified by PCR and in situ hybridisation. RESULTS The immunohistochemical studies revealed CD20+ germinal centres with prominent staining of CD23+ dendritic reticular cells, surrounded by numerous interfollicular CD3+, and CD4+ or CD8+ T-cells. Factor VIII-related antigen, CD31 and CD34 occurred in the thin-walled blood vessels. The reactivity of CD1a, HHV-8 and EBV-associated latent membrane protein 1-EBV (LMP1-EBV) were negative, and in situ hybridisation confirmed the lack of EBV DNA. No patient recalled an external insult or chronic irritation. CONCLUSIONS The results of this study indicate the reactive nature of H&N-KD (or a subset of H&N-KD), and it is unlikely that HHV-8 and EBV play a role in the pathogenesis of the lesion. However, the patients in this series did not have previous history of trauma or chronic irritation; thus, a neoplastic origin could not be excluded. Further multicentre studies based on more specimens are warranted.

The application of acetic acid in the detection of oral squamous cell carcinoma.

BACKGROUND Oral cancer is the fourth most common cancer in males and the seventh most common cancer in females in Thailand. The survival rates and quality of life of oral cancer patients will significantly be improved if they receive treatment for lesions that are less advanced or premalignant. Early diagnosis is therefore of paramount importance. A number of techniques have been developed to supplement clinical examination for oral malignancy. One interesting screening method is the application of 3% to 5% acetic acid, which has been used for cervical cancer screening. OBJECTIVES The primary objective of this study was to assess the sensitivity, specificity, and accuracy of using vinegar (5% acetic acid) for the examination of oral cancer. The secondary objective was to investigate the association between clinical examination using acetic acid and expression of the tumor marker, p53. METHODS The study included 30 participants suspected of having oral squamous cell carcinoma. Five percent acetic acid was applied to the lesions, followed by incisional biopsy. The specimens were microscopically examined for pathological diagnosis and p53 immunohistochemical investigation. RESULTS The sensitivity, specificity, and accuracy of using acetic acid for oral cancer examination were 83.33%, 84.21%, and 83.64%, respectively. There was a statistically significant association between clinical examination using acetic acid and expression of p53 protein (P = .000). CONCLUSIONS The results of this study suggest that 5% acetic acid has high sensitivity, specificity, and accuracy in detecting oral squamous cell carcinoma and might be used as an adjunct for oral cancer examination.