Michael Lypka

Aggressive osteoblastoma of the mandible

We report a case of aggressive osteoblastoma of the mandible, an extremely rare primary bone tumor of the maxillofacial skeleton. Although osteoblastomas are benign tumors requiring only curettage for cure, there is a small subset of tumors that exhibit locally aggressive behavior and have atypical histopathologic features. Differentiation from low-grade osteosarcoma is often difficult. There is some disagreement as to the proper classification of these tumors. The correct diagnosis must be based on clinical, radiographic and pathologic features. Surgical resection and reconstruction is the recommended treatment for these invasive lesions.

rhBMP-2 with a demineralized bone matrix scaffold versus autologous iliac crest bone graft for alveolar cleft reconstruction.

Background: Secondary alveolar cleft reconstruction using autologous iliac crest bone graft is currently the standard treatment for alveolar clefts. Although effective, harvesting autologous bone may result in considerable donor-site morbidity, most commonly pain and the potential for long-term sensory disturbances. In an effort to decrease patient morbidity, a novel technique using recombinant human bone morphogenetic protein (rhBMP)-2 encased in a demineralized bone matrix scaffold was developed as an alternative to autografting for secondary alveolar cleft reconstruction. Methods: A chart review was conducted for the 55 patients who underwent secondary alveolar cleft reconstruction over a 2-year period with a mean follow-up of 21 months. Of these, 36 patients received rhBMP-2/demineralized bone matrix scaffold (including 10 patients with previously failed repairs using iliac crest bone grafting) and 19 patients underwent iliac crest bone grafting. Postoperatively, bone stock was evaluated using occlusal radiographs rated according to the Bergland and Chelsea scales. Results: Alveolar clefts repaired using rhBMP-2/demineralized bone matrix scaffold were 97.2 percent successful compared with 84.2 percent with iliac crest bone grafting. Radiographically, initial repairs with rhBMP-2/demineralized bone matrix scaffold were superior to iliac crest bone grafting according to both Bergland and Chelsea scales, and significantly more patients in the rhBMP-2/demineralized bone matrix scaffold group had coronal bridging. The postoperative intraoral infection rate following iliac crest bone grafting was significantly greater than for rhBMP-2/demineralized bone matrix scaffold. The cost of rhBMP-2/demineralized bone matrix scaffold products was offset by cost savings associated with a reduction in operative time averaging 102 minutes. Conclusions: rhBMP-2 encased in a demineralized bone matrix scaffold appears to be a viable alternative for secondary alveolar cleft repair. Patients are spared donor-site morbidity and achieve excellent results, decreasing operative time, and increasing operating room use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Posterior Pharyngeal Augmentation in the Treatment of Velopharyngeal Insufficiency: A 40-Year Experience

Background:Velopharyngeal insufficiency (VPI) remains a common problem in the care of patients with cleft palate and other related conditions. It may be successfully corrected with augmentation of the posterior pharynx. The purpose of this study was to review the experience and results of posterior pharyngeal augmentation over a 40-year period at one cleft center in the United States. Methods:All patients from 1968 to 2008 who underwent posterior pharyngeal augmentation for the treatment of VPI were reviewed retrospectively. Diagnosis, age at the time of operation, type of implant used, duration of follow-up, speech performance both pre- and postoperatively, and complications were analyzed. Speech performance preoperatively was assessed by video fluoroscopy and/or nasoendoscopy. Resonance was assessed by both the surgeon and speech pathologist using a 4 point grading scale. Results:One hundred eleven patients underwent posterior pharyngeal augmentation. Thirteen patients required removal of the implant because of extrusion (n = 12) or postoperative sleep apnea (n = 1). Five patients with failed implants at the primary operation had successful replacement at a second operation, resulting in a retained implant success rate of 93%. Of the 103 patients who were successfully augmented, 15 were lost to follow-up, leaving 88 patients with full postoperative speech evaluations. Of the 88 patients evaluated, 64 exhibited normal or near normal speech (73%), 22 patients had mildly nasal speech (25%), and 2 patients (2%) were not improved. Highest extrusion rates were seen for smooth surface silicone and rolled gortex implants. Conclusion:Augmentation of the posterior pharyngeal wall is a safe and effective treatment for patients with VPI. Implants are well tolerated and speech is substantially improved.

Dental Implant Reconstruction in a Patient With Ectodermal Dysplasia Using Multiple Bone Grafting Techniques

Ectodermal dysplasia is a syndrome in which 2 ectodermally derived structures fail to develop. Patients have a reduced number of teeth, and dental implant reconstruction is the preferred method of replacing teeth. We report the use of the tent pole technique in the severely resorbed mandible with sinus lifts and block grafting in the maxilla to restore the maxillofacial complex of a female patient with ectodermal dysplasia. The treatment sequence and techniques are discussed.

Postoperative Alopecia Following Orthognathic Surgery

Postoperative alopecia is a pressure-induced, circumscribed area of occipital hair loss, usually after lengthy operative procedures. Prolonged hair follicle ischemia, a result of constant pressure from improper head positioning, is thought to be causative. Most commonly a reversible condition, it can be quite distressing for a patient. The maxillofacial surgeon must understand the pathophysiology and natural history of the condition to correctly identify it and employ measures to prevent it. Here we report a case of postoperative (pressure) alopecia in a female patient after orthognathic surgery. Report of a Case A 37-year-old female underwent Le Fort I osteotomy, bilateral sagittal split osteotomies, and sliding genioplasty to correct a dentofacial deformity, consisting of vertical maxillary excess, mandibular deficiency, and retrogenia. The patient’s head was positioned in the usual fashion, by first placing a head drape, and then resting it on a foam doughnut. The patient had very long hair that had to be gathered posteriorly into the head drape. The 5-hour surgery progressed without complications using a hypotensive anesthesia technique. Mean arterial blood pressure during the case was 65. The patient was discharged on postoperative day 2. At the 3-week follow-up, the patient complained of a “bald” spot at the occipital region near the vertex of the scalp (Fig 1). Upon further questioning, the patient reported a slight discomfort in this area the preceding 3 weeks, but no swelling or ulceration. The patient was reassured and had resolution of hair loss 6 months later.

Defining the role for submental intubation

Submental intubation, a less invasive alternative to tracheostomy, was first described for acute airway management of maxillofacial trauma patients, where nasoendotracheal intubation was contraindicated and oral intubation was not possible due to the desire to establish dental relationships perioperatively. While submental intubation is used most commonly in trauma patients, the range of indications for its use has broadened to include many orthognathic and skull base surgical procedures. Submental intubation is a safe, effective technique for many maxillofacial procedures, requiring the cooperation of both anesthesiologists and maxillofacial surgeons.

Median facial cleft dysmorphism in three siblings: case report and review of the literature.

Cleft of the facial midline is an extremely rare entity, occurring in probably less than 1 per 100,000 births (Kawamoto and Patel, 1998). Median facial cleft may present with a wide spectrum of features, including hypertelorbitism, V-shaped frontal hairline, bifid cranium, broad nasal root, bifid nose, median cleft of the upper lip, and median cleft of the premaxilla (Urata and Kawamoto, 2003). This condition is most commonly known as a 0–14 cleft, as classified by Tessier (1976), but multiple other classifications and terminologies have been proposed (DeMyer, 1963; Sedano et al., 1970; Cohen, 1982; van der Meulen et al., 1983; Kawamoto and Patel, 1998). In this article, we will refer to all cases as median facial cleft dysmorphism, as suggested by Kawamoto and Patel (1998). Genetic inheritance is most commonly sporadic, with other reported cases suggesting an autosomal dominant or Xlinked dominant inheritance pattern. We report three cases of median facial cleft dysmorphism, all of which occurred in siblings of the same family; we describe the clinical features and give support to the published literature suggesting an autosomal dominant inheritance pattern.

Journey to chew: a case of maxillary duplication and bony syngnathia.

Tessier no 3 cleft, bony syngnathia, and maxillary duplication are rare as independent anomalies and have never been reported together in a single case. Here we present a patient with congenital bony syngnathia, maxillary duplication, and a Tessier no. 3 nasal cleft. Other abnormalities included situs inversus, dextrocardia, coarctation of the aorta, left choanal stenosis, left coloboma, and hypertelorbitism. Given the unique presentation, we present our early surgical management to this complex problem.

Delayed Middle Cranial Fossa Perforation After Autologous Temporomandibular Joint Reconstruction

The temporomandibular joint (TMJ) is a ginglymoarthrodial joint housed in a small anatomic area by the brain superiorly, the hearing apparatus posteriorly, the facial nerve anteroinferiorly, and large vessels medially. Given its complex anatomy in both form and function, when resected for various pathologic entities, such as tumor, ankylosis, or degenerative arthritis, it represents a reconstructive challenge for the most experienced maxillofacial surgeon. Various options for reconstruction of the TMJ have included both autologous methods such as costochondral grafts or distraction osteogenesis and prosthetic methods. Although many successful recontructions have been performed using both methods, omplications have arisen. In this report, we have foused our attention on the middle cranial fossa violation fter TMJ reconstruction. Probably the most notable xample is the foreign body giant cell reaction to Teflonroplast implants placed in the 1980s that caused erosion into the middle cranial fossa in some cases. Also reported after other prosthetic condylar reconstructions, the same complication has never been reported fter autologous reconstruction. In this brief report, we escribe a middle cranial fossa perforation after autoloous reconstruction of the TMJ with a costochondral raft.

A simplified lateral canthopexy technique.

Sir:Lateral canthopexy has become a routine part of cosmetic lower blepharoplasty to prevent lower lid malposition, especially in those patients with laxity of the lower lid and negative vector anatomy.1 All canthopexy techniques involve securing the lateral retinaculum to the periosteum of the supe