Larry L. Cunningham

Patient benefit from endoscopically assisted fixation of condylar neck fractures--a randomized controlled trial.

PURPOSE Owing to the risk of facial nerve damage and the creation of visible scars, surgical treatment of condylar mandible fractures using an extraoral approach remains controversial. The transoral endoscopically assisted approach of condylar fractures has been reported to avoid these complications. A prospective, randomized controlled, multicenter trial was performed to quantify the patient benefit after open reduction and internal fixation of condylar mandible fractures using endoscopically assisted treatment compared with surgical treatment without endoscopic assistance. PATIENTS AND METHODS Patients with dislocated uni-/bilateral condylar neck fractures were randomized to receive either nonendoscopic open reduction and internal fixation using an extraoral (submandibular, preauricular, retromandibular) approach or a transoral endoscopic procedure. The primary functional outcome measure was investigated using the asymmetric Helkimo dysfunction score at 8 to 12 weeks and 1 year after surgery. RESULTS A total of 74 patients were recruited between 2003 and 2006; the nonendoscopic extraoral group included 34 patients and the endoscopically assisted open reduction group included 40 patients. Comparable functional results were noted in both groups without any statistical significance. Endoscope-assisted treatment proved to be more time consuming. For the extraoral group, visible scars were rated by most of these patients as being cosmetically acceptable; however, a greater number of facial nerve injuries were reported. CONCLUSIONS The treatment of condylar mandible fractures with a minimal invasive endoscopically assisted technique is reliable and may offer advantages for selected cases, particularly concerning the lower occurrence of facial nerve damage.

Temporary anchorage device insertion variables: effects on retention

OBJECTIVE To quantify the influence of temporary anchorage device (TAD) insertion variables on implant retention. MATERIALS AND METHODS Three hundred thirty TADs from three companies were placed in synthetic bone replicas at variable depths and angulations and compared. Clinically relevant forces were applied to the TADs until failure of retention occurred. RESULTS In all three implants, increased insertion depth increased implant retention. As the distance from the abutment head to the cortical plate increased, the retention of all three implants decreased. A significantly greater force to fail was required for a 90 degrees insertion angle than for 45 degrees or 135 degrees insertion angles. No significant difference was found between the 45 degrees and 135 degrees insertion angles. A significant reduction in force to fail occurred when comparing 90 degrees and 45 degrees oblique insertion angles. CONCLUSIONS Increasing penetration depth of TADs results in greater retention. Increased abutment head distance from cortical plate leads to decreased retention. Placement of TADs at 90 degrees to the cortical plate is the most retentive insertion angle. Insertion at an oblique angle from the line of force reduces retention of TADs.

Current Thoughts on Treatment of Patients Receiving Anticoagulation Therapy

b c a b T i t K T t 2 s c p o c a p d b m c a m t k t g d r d m i p I t n w e t p p a t is common for oral and maxillofacial surgeons to treat atients who are receiving oral anticoagulation therapy OAT). The standard of care for patients taking warfarin as been to admit them to the hospital, discontinue their nticoagulation therapy, and use bridging therapy with ntravenous heparin until surgery. Heparin is then disontinued 6 hours before surgery and resumed postopratively. Warfarin administration is also resumed postperatively, and the heparin administration can be iscontinued when the international normalized ratio INR) has reached the therapeutic level. Such proceures are typically required for 3 to 4 days before surery so that the patient’s INR can normalize. The stanard of care for patients receiving antiplatelet therapy as been to discontinue their medication 10 days before urgery and then to restart the medication 24 to 48 ours later. The published data have suggested that a odification of this standard might provide patients eceiving anticoagulation and their surgeons a safer and ore efficient perioperative course. We have presented review of this topic, including a brief description of the ore commonly encountered anticoagulant and antilatelet medications, a review of the recent published ata on local hemostatic agents, and the current recomendations for the surgical treatment of these patients.

Management of Atrophic Mandible Fractures: Are Bone Grafts Necessary?

r t 2 t t a d h C 1 l g U c t t t a w t p anagement of patients with atrophic mandible fracures has been a challenge for maxillofacial surgeons or years. Techniques that have been used are plints, external pins, split ribs wire osteosynthesis, nd rigid fixation. Results with each of these techiques have had variable success depending on the mount of atrophy that the patient underwent before njury. There has been an evolution of treatment over he years in which closed techniques have been gradally replaced by open techniques. In 1976, ruce and Strachan suggested that closed reductions hould be tried first and that if an open reduction was equired, wire mesh was preferable to a bone plate. n 1979, Marciani and Hill, after reviewing 33 wellocumented cases, recommended that a closed reuction of fractures of the atrophic mandibular body e done. In the second Chalmers J. Lyons Academy tudy, published in 1993, Bruce and Ellis noted that 1.5% of the 104 patents had an open reduction and nternal fixation with a bone plate. In 1996, Luhr et al resented their results in 84 patients with atrophic dentulous mandible fractures treated with compresion bone plates. In 2006, Wittwer et al reviewed heir outcomes of the treatment of 30 patients treated ith different plating systems. They concluded that he more atrophic a fractured mandible is, the more igid the fixation of the fracture needed to be. Tiwana t al, in 2009, suggested that for ideal healing of dentulous, atrophic mandible fractures, bone graftng is needed in addition to a large reconstruction late and a bone graft. The patient population with atrophic mandible ractures is different in several ways from the average

Development of imiquimod‐loaded mucoadhesive films for oral dysplasia

Oral squamous dysplasia, which can usually be readily visualized as leukoplakia during an oral examination and confirmed by histology, is often considered a premalignant condition. Current treatments, however, focus on the final stages of disease, and treatments such as surgery can lead to postoperative disabilities. Hence, this study was designed to develop a noninvasive, mucoadhesive drug delivery system loaded with an immune response modifier, imiquimod, as a treatment for precancerous dysplastic lesions. Blends of polyvinylpyrrolidone and carboxymethylcellulose were used to prepare mucoadhesive films that were backed with poly(ethylene-co-vinyl acetate). Because of the hydrophobic nature of imiquimod, four loading methods (sonication, linoleic acid, 2-hydroxypropyl-β-cyclodextrin, and acetate buffer) were compared. The formation of imiquimod-cyclodextrin complexes and their solubility was studied by differential scanning calorimetry and phase solubility studies. All films achieved sustained release of drug for 3 h except those prepared by linoleic acid. The high solubility of imiquimod in acetate buffer facilitated high loading capacity and greater release (68%) of drug than did the other formulations (approximately 40%). In summary, a noninvasive and local approach with the potential to treat precancerous lesions may be achieved by this described mucoadhesive drug delivery system.

Rash Associated with Pregabalin Use

Objective: To report a case of extensive rash induced by orally administered pregabalin in a patient with neuropathic pain. Case Summary: A 35-year-old white female with a diffuse, erythematous, maculopapular rash localized to her back and extremities presented to the preoperative holding area for planned exploratory nerve surgery. Prior to presentation, she had been receiving oral pregabalin 50 mg 3 times a day for approximately 2 weeks to treat her neuropathy. Prior to pregabalin therapy, the patient indicated that she had taken gabapentin for approximately 3 weeks for the pain, but had discontinued it due to adverse effects and perceived lack of efficacy. Pregabalin was discontinued and diphenhydramine and methylprednisolone were given to treat the rash. The rash almost completely resolved one week after pregabalin was discontinued. Discussion: Pregabalin-induced rash was rarely reported in Phase 3 trials, and a clinical description of such events has not been published. Pregabalin exhibits pharmacokinetics different from those of most other antiepileptic agents. Presently, there are no clear mechanisms known for rash associated with pregabalin. The Naranjo probability scale indicates a probable relationship between the development of rash and use of pregabalin by our patient. Conclusions: There are currently no other available reports of the development of a rash coinciding with the use of pregabalin. As both Food and Drug Administration–approved and off-label use of this drug increases, further consideration of risk factors associated with the development of rash is needed.

Complications of frontal sinus fractures with emphasis on chronic craniofacial pain and its treatment: a review of 43 cases.

PURPOSE Frontal sinus fractures constitute 5% to 12% of all facial fractures. The optimal management of frontal sinus fractures is controversial but involves preserving the function of the nasofrontal ducts when feasible. We reviewed the postoperative complications of a series of 43 patients treated surgically for frontal sinus fractures. MATERIALS AND METHODS The data from 43 patients treated from 2000 to 2006 were reviewed. The information reviewed included patient age and gender, mechanism of injury, type of frontal sinus injury, associated facial injuries, treatment method, and complications. The institutional review board approved the present study. RESULTS The average patient age was 32.5 years; 36 were men and 7 were women. Of the 43 patients, 23 (53.5%) had had anterior table fractures and 20 (46.5%) had had both anterior and posterior table fractures. Postoperative complications occurred in 7 patients (16.3%). Of these 7 patients, 2 experienced continued headache and pain and required surgical removal of infected hardware, 3 also experienced frequent headaches and pain in the frontal-temporal region, 1 had a post-traumatic deformity, and 1 developed periorbital cellulitis and abscess formation within the frontal sinus. CONCLUSION Frequent headaches and complaints of continued pain were the most common complications experienced by our series of patients. We also reviewed treatment strategies for postoperative follow-up and treatment of chronic pain.

Competing properties of mucoadhesive films designed for localized delivery of imiquimod

Oral mucosal delivery has gained prominence in the last two decades because the rich vasculature of the tissue enables rapid delivery and avoidance of first pass metabolism. Although commercial mucoadhesives are used for systemic delivery, systems are not currently available for treatment of local conditions. In the present work, mucoadhesive films are being developed for locally controlled release of an immune response modifier for preventing precancerous lesions from progressing to oral squamous cell carcinoma. Previous research showed that films composed of polyvinylpyrrolidone (PVP) and carboxymethylcellulose (CMC) released imiquimod in a sustained manner for 3 hr. In continuing development of the system, additional key properties were investigated with changes in composition. While adhesive properties in pull-off (0.42±0.03 to 1.1±0.1 N/cm2) and shear adhesion (1.7±0.25 to 5.6±1.4 N/cm2) increased with increasing PVP content of films, tensile properties, such as modulus (6.9±1.5 to 1.8±0.2 MPa) and ultimate strength (4.2±0.7 to 2.1±0.02 MPa), decreased as PVP content increased. Release profiles of the films showed that an increased PVP content resulted in burst release and faster erosion compared to sustained release and slower erosion with more CMC. Studies of transport kinetics showed that the films doubled the amount of imiquimod localized within epithelium compared to drug in solution, increasing their potential for local treatment of oral dysplasia. The mucoadhesive drug delivery system based on CMC and PVP offers a wide range of these properties without addition of new constituents.

Intraosseous Venous Malformation of the Mandible: A Review on Interdisciplinary Differences in Diagnostic Nomenclature for Vascular Anomalies in Bone and Report of a Case

f s l a Vascular anomalies often affect the soft tissues of the maxillofacial region but are rarely found in bone. They account for fewer than 1% of all bony “tumors” and are most frequently described in the vertebral column and calvarium. The maxilla and mandible are the most commonly affected bones of the facial skeleton. Intraosseous vascular anomalies have also een described in the literature to be found within he zygoma, orbit, and condyle. Because of their ability to cause significant hemorrhage after relatively minor insults, intraosseous vascular anomalies can be life-threatening entities. Spontaneous hemorrhage is reported to have caused at least 25 deaths. Patients with intrabony vascular lesions have developed bleeding from dental cleanings and undergone biopsies and simple extractions of teeth. Some of these have resulted in severe hemorrhage, airway compromise, or exsanguination.

The endoscopic brow and midface lift.

Improvements in technology have increased the level of patient care in all aspects of medicine and surgery. This is no less true in the area of cosmetic surgery. The use of endoscopy has led to improved aesthetics with respect to postoperative scarring, decreased healing time for patients, and an increase in overall patient satisfaction. Because the endoscopic brow and midface lift accomplishes the three primary goals of facial cosmetic surgery (restoration, rejuvenation, and enhancement) while adhering to the concepts of working from inside out and repositioning rather than excising, it could be concluded that there is no longer any indication for either the coronal or trichophillic brow lifts. An argument could be made that a direct brow lift may be indicated in cases of extreme brow ptosis with deep frontal rhytids to allow concealment of the scar; however, even moderate-to-severe brow ptosis can be corrected endoscopically when deep forehead rhytids are not present.