Michael Miloro

Modification of the sinus lift procedure for septa in the maxillary antrum.

The sinus lift procedure with bone grafting was introduced by Tatum in 1975, ’ who described an alveolar crestal approach. Boyne and James were the first to describe the lateral osteotomy.2 Since this description in 1980 the lateral approach has been modified several times.3‘5 The technique of sinus lift may be difficult if aberrant sinus anatomy, such as a septum of the sinus floor, is encountered during surgical exposure. Radiating septa of varying sizes can form from the sinus floor in the intervals between adjacent teeth.6 These septa divide the sinus into two or more cavities.’ The septa are usually knife-edged and extend from the inner to the outer walls, reinforcing the osseous architecture of the antrum.8 The incidence of antral septa is unknown. Jensen and Greer infrequently encountered “abnormal sinus variations” in 15 patients who had 26 antral grafts.’ However, it is our personal experience that sinus septa are encountered during approximately 20% of sinus elevation procedures. If septa are not identified prior to the initiation of the sinus lift procedure, extreme difficulty may be encountered when attempting to infracture and elevate the bony window. Also, because the sinus membrane is strongly adherent to the septa, elevation without perforation may be difficult. 3,9 In addition, because a septum can divide the sinus into two separate compartments, opening into only one cavity may not allow adequate access for bone grafting. This report describes a modification of the standard sinus lift procedure when sinus septa are encountered.

Alveolar Osteitis: A Comprehensive Review of Concepts and Controversies

Alveolar osteitis, “dry socket”, remains amongst the most commonly encountered complications following extraction of teeth by general dentists and specialists. A great body of literature is devoted to alveolar osteitis addressing the etiology and pathophysiology of this condition. In addition numerous studies are available discussing methods and techniques to prevent this condition. To this date though great controversy still exists regarding the appropriate terminology used for this condition as well as the actual etiology, pathophysiology, and best methods of prevention and treatment. This article is a comprehensive critical review of the available literature addressing the concepts and controversies surrounding alveolar osteitis. We aim to assist the dental health care professional with patient preparation and management of this commonly encountered postoperative condition should be encountered.

Discectomy as the Primary Surgical Option for Internal Derangement of the Temporomandibular Joint

PURPOSE The goal of this study was to evaluate outcomes of patients who underwent temporomandibular joint (TMJ) discectomy without replacement as the primary treatment for internal derangement after failure of nonsurgical therapy. PATIENTS AND METHODS Thirty consecutive patients with TMJ internal derangement were treated with discectomy from 2001 to 2007. Four patients were lost to follow-up, and 2 were excluded because of prior joint surgery. Using the standardized Helkimo Anamnestic and Clinical Dysfunction Indexes, 24 patients, or 32 joint surgeries, were evaluated postoperatively, with an average follow-up of 30.8 months (range, 2 to 60 months). RESULTS All 24 patients showed improvement in mandibular mobility and joint function, as well as reduction in TMJ and muscular facial pain, represented by a clinical dysfunction index of DiO, DiI, or DiII. Preoperatively, all patients had an anamnestic index of AiII, which represented moderate to severe pain in the TMJ and masticatory muscles, and/or locking of the joint before surgery. Postsurgically, 20 of the 24 patients scored an index of DiO or DiI, which correlated with a clinically symptom-free state or only a small, minor dysfunction. TMJ pain, muscle pain, and pain with mobility scored the lowest point index, indicating a subjectively successful outcome. CONCLUSIONS Discectomy of the TMJ as a primary surgical option significantly reduces pain and improves function.

Cervical Necrotizing Fasciitis With Descending Mediastinitis: Literature Review and Case Report

Cervical necrotizing fasciitis (CNF) can develop from odontogenic infections that spread to the deep fascial planes of the neck. This polymicrobial infection is rapidly progressive, destructive, and often fatal. Prompt diagnosis, recognition of acuity, aggressive, repeated surgical treatment, and medical management contribute to improved survival. Nevertheless, the progression of the disease to descending mediastinitis and septic shock leads to a poor prognosis and decreased survival. A comprehensive review of the current data regarding CNF was conducted using MEDLINE, PubMed, Scopus, and Google Scholar. The diagnostic elements, comorbid conditions, treatment modalities, complications, and survival rates were analyzed. CNF has a reported mortality rate of 7% to 20%, depending on the extent of neck involvement. When the disease progresses into the thorax, such as in the subset of patients with CNF complicated by descending necrotizing mediastinitis (DNM) of odontogenic origin, the mortality rate increases to 41%. This is greater than the reported mortality rate of 22% for DNM in cardiothoracic studies. When DNM is present, the risk of developing septic shock appears to be much greater, 22% versus 7%. In the presence of CNF, DNM, and sepsis, the mortality rate increases to 64%. Those who survive CNF complicated by DNM and sepsis have truly beaten the odds. CNF is an uncommon, but potentially fatal, condition that oral and maxillofacial surgeons might be called on to manage emergently. Treatment includes surgery and medical intensive care. Surgeons offer the best odds of patient survival by following these basic principles: airway security, early aggressive incision and drainage plus debridement with thoracotomy, as needed, close surveillance with computed tomography, and a low threshold for retreatment. In immunocompromised patients, even greater vigilance is required. Antibiotic therapy should be adjusted as cultures and sensitivities become available. Advances in interventional radiology might lead to improved survival by allowing guided minimally invasive drainage in critically ill patients who cannot tolerate additional surgical insult. Despite the technologic advances in diagnosis and treatment, CNF complicated by DNM mediastinitis and sepsis still results in astoundingly high mortality.

Stability of Open Bite Correction With Sagittal Split Osteotomy and Closing Rotation of the Mandible

PURPOSE To determine the long-term stability of bilateral sagittal split osteotomies with counterclockwise (closing) rotation of the mandible combined with rigid internal fixation in the correction of anterior open bite deformities. MATERIALS AND METHODS A total of 28 patients who had completed orthodontic therapy and had at least 1 year of postoperative follow-up were evaluated using cephalometric analysis for dental and skeletal changes. We evaluated 7 angular and 6 linear measurements cephalometrically at 3 points for each patient: immediately preoperatively, immediately postoperatively, and after a minimum of 1 year of postoperative follow-up. RESULTS Of the 28 patients, 12 exhibited some degree of opening rotation (range 1% to 64%, mean 16%), and 16 showed no open rotation or continued to experience bite closure. However, all patients had a positive overbite at 1 year of follow-up, indicating that even though skeletal relapse was observed postoperatively, dental compensation resulted in the maintenance of the occlusal relationships. CONCLUSIONS Bilateral sagittal split osteotomies and closing rotation of the mandible using rigid fixation is a relatively stable procedure and a viable surgical treatment option for the correction of anterior open bite in instances in which maxillary osteotomies are not indicated to improve or enhance facial esthetics.

Clinical Evaluation of Implants in Radiated Fibula Flaps

PURPOSE The success of osseointegrated implants in the radiated fibula flap used for mandibular reconstruction is variable, and there are few long-term data available in the literature. The purpose of this study is to evaluate implant success in radiated fibula flaps and the native mandible after ablative tumor surgery. MATERIALS AND METHODS The medical records of 44 patients who underwent resection and reconstruction of the mandible from 1994 to 2006 were reviewed retrospectively. A total of 206 implants were placed; 144 were placed in a fibula flap, and 92 were placed in the native mandible. Before implant placement, 22 patients (50%) received adjuvant tumoricidal doses of radiation therapy (>6,000 cGy). All patients who received radiation received a standard regimen of 20 preoperative and 10 postoperative hyperbaric oxygen treatments. The follow-up period ranged from 4 to 108 months (mean, 41.1 months). Comparisons were made between groups regarding long-term implant success based on several variables. RESULTS Implants were considered to be successful if there was no radiographic evidence of peri-implant bone loss and if they were clinically osseointegrated. Of 206 implants, 31 failed, with an overall success rate of 85%. The success rate of implants placed in fibula flaps was 82.4%, and the success rate in native mandibles was 88%. Most of the failures in the fibula (90%) occurred within the first 6 months after implant placement, whereas most of the failures in the mandible occurred after 6 months. The cumulative survival rate was 91.9%, and there was no difference in survival between implants placed in the fibula versus the native mandible or depending on whether the patient received radiation therapy. CONCLUSION Acceptable long-term implant success rates may be achieved in the radiated mandible with vascularized fibula flap reconstruction.

Fracture of the styloid process: A case report and review of the literature

Trauma to the styloid process of the temporal bone appears to be an extremely rare occurrence,’ although this is probably largely attributable to a failure in adequate recognition and diagnosis. The actual incidence of styloid process fracture is very much higher than has been reported. The literature contains a paucity of articles devoted to fracture of the styloid process and its management, with only 20 cases published in the English literature since the turn of the century (Table 1). This report describes a case of traumatic styloid process fracture associated with bilateral mandibular fractures that was managed conservatively.

Bone Healing in a Rabbit Mandibular Defect Using Platelet-Rich Plasma

PURPOSE To evaluate the effect of platelet-rich plasma (PRP) on bone healing in an osteotomized defect of the rabbit mandible. MATERIALS AND METHODS Twelve adult female New Zealand White rabbits were randomized to 1 of 2 treatment groups: group A had an osteotomy with the addition of a bone graft, and group B had an osteotomy without a bone graft. Regardless of treatment group, 1 side in each rabbit was randomly selected to receive PRP as an internal control. Bilateral 1.0- x 0.5-cm mandibular inferior border osteotomies were performed in each animal, 0.5 cm anterior to the antegonial notch to create mandibular defects. The osteotomy sites were evaluated by histologic and radiographic analyses for bone healing at 1, 2, and 3 months after surgery. RESULTS A 4-point ordinal scale was used to compare healing, based on radiographic density, radiographic height, and histologic height of new bone formation. Group A rabbits showed significantly shorter healing times compared with group B rabbits. A pairwise analysis indicated that the addition of PRP did not increase the overall score of any measured parameter, at any interval (P > .9). CONCLUSIONS In the rabbit osteotomy model, bone grafting (group A) significantly improved healing in comparison with no bone grafting (group B). In defects of the mandible, an increased radiographic and histologic bone density and height were seen at 1-, 2-, and 3-month intervals in the bone graft group; however, the addition of PRP did not appear to provide any statistically significant benefit to healing in either group.

Temporomandibular Joint Replacement for Ankylosis Correction in Nager Syndrome: Case Report and Review of the Literature

p o l i a Nager acrofacial dysostosis is a mandibulofacial abnormality characterized by downward slanting of the palpebral fissures, malar hypoplasia, bilateral conductive hearing loss, cleft palate, micrognathia, absent or hypoplastic thumbs, and radial limb hypoplasia. The syndrome shares many phenotypic features with Treacher-Collins syndrome; however, it is recognized as a separate clinical entity. A comprehensive review of the published data regarding Nager syndrome was completed to better understand the syndrome itself and the multiple treatment modalities historically used for correction of the variety of clinical manifestations, including mandibular retrognathism. In addition, we present the 94th reported case of Nager syndrome and the correction of bilateral temporomandibular joint (TMJ) ankylosis, resulting from multiple failed previous mandibular surgeries, with bilateral custom total TMJ prosthetic replacement. Nager syndrome, also known as Nager acrofacial dysostosis, was first described and distinguished from other acrofacial disorders in 1948 by Nager and Derenier. It is a genetic craniofacial disorder with varying opinions regarding its etiology, thereby suggesting a possible heterogeneous pathogenesis. An

Is there consistency in cephalometric landmark identification amongst oral and maxillofacial surgeons

There may be significant variation amongst oral and maxillofacial surgeons (OMFS) in the identification and placement of cephalometric landmarks for orthognathic surgery, and this could impact upon the surgical plan and final treatment outcome. In an effort to assess this variability, 10 lateral cephalometric radiographs were selected for evaluation by 16 OMFS with different levels of surgical knowledge and experience, and the position of 21 commonly used cephalometric landmarks were identified on radiographs displayed on a computer screen using a computer mouse on a pen tablet. The database consisted of real position measurements (x, y) to determine the consistency of landmark identification between surgeons and within individual surgeons. Inter-examiner analysis demonstrated that most landmark points had excellent reliability (intra-class correlation coefficient >0.90). Regardless of the level of surgeon experience, certain landmarks presented consistently poor reliability, and intra-examiner reliability analysis demonstrated that some locations had a higher average difference for both x and y axes. In particular, porion, condylion, and gonion showed poor agreement and reliability between examiners. The identification of most landmarks showed some inconsistencies within different parameters of evaluation. Such variability among surgeons may be addressed by the consistent use of high-quality images, and also by periodic surgeon education of the definition of the specific landmarks.