Michael Peleg

Platelet-rich plasma for bone graft enhancement in sinus floor augmentation with simultaneous implant placement: patient series study.

The use of autologous platelet-rich plasma (PRP) as a source for growth factors in bone grafting is a relatively new and promising technique. Early controlled studies indicate that combining PRP with autologous bone grafts significantly enhances the rate of bone formation and maturation. The study consisted of 105 patients who required sinus augmentation with crestal bone height of less than 5 mm in the posterior maxilla. All patients received a composite bone graft that consisted of 30% to 40% autogenous bone harvested from the lateral wall of the maxilla zygomatic–maxillary buttress and the tuberosity and 60% to 70% xenograft. A total of 50 mL of blood was obtained from each patient before the surgical treatment for preparation of 10 mL of PRP. The graft–PRP mixture was activated by human thrombin. All sinus augmentations were carried out simultaneously with dental implants. At 6 months postoperatively, implants were exposed showing no clinical evidence of crestal bone loss around the implants both clinically and radiographically. All implants were clinically osseointegrated and loaded with fixed porcelain fused to metal prosthesis. The use of PRP in augmenting the severely atrophic posterior maxilla has obvious clinical benefits in terms of reducing the healing period of bone maturation, better graft handling, and accelerated soft tissue healing.

Patterns of metastases to the upper jugular lymph nodes (the “submuscular recess”)†

Cervical lymphadenectomy to remove metastatic disease in level II encompasses lymph nodes associated with the upper third of the internal jugular vein and the adjacent spinal accessory nerve (SAN). Conservative neck dissection (ND) preserves these structures but requires manipulation of the SAN to remove tissue located in the posterosuperior aspect of level II. Limiting the dissection to the nodal group anterior to the SAN may reduce operating time and limit injury to it without compromising the removal of lymph nodes at risk for involvement with cancer.

Lingual cyst with respiratory epithelium: an entity of debatable histogenesis.

PURPOSE The purpose of this report was to describe a new case of lingual cyst with respiratory epithelium, to review and analyze the literature regarding lingual cyst of foregut origin and lingual alimentary cyst, and to discuss the suitable terminology for these uncommon cysts. MATERIAL AND METHODS Data from articles published in the English language between the years 1942 and 1947 were used. RESULTS The review of the literature showed 53 lingual cysts of which 29 could be grouped into lingual alimentary tract cysts and 24 into lingual cysts of foregut origin. There was an overlap in histologic and clinical features and embryogenesis of both cysts. CONCLUSIONS Differentiation between both cysts cannot be supported, and until further information is accumulated it is suggested that histologic descriptive terms be used such as lingual cyst with respiratory epithelium, lingual cyst with gastric epithelium, or lingual cyst with respiratory and gastric epithelium.

Changing indications for tracheostomy in maxillofacial trauma

PURPOSE Tracheostomy is one of the most common surgical procedures, but not always without complications. The purpose of this article was to reevaluate the indications of maintaining the airway with the use of tracheostomy. MATERIALS AND METHODS A total of 399 patients with maxillofacial trauma, who were treated in the Maxillofacial Surgery Department from 1985 to 1992, were evaluated for the type of fracture and air-way problems. RESULTS Out of the 399 patients evaluated, 13 needed a tracheostomy. Of these, 6 had had a cricothyroidotomy on arrival, 3 required tracheostomy because of impending airway obstruction, 3 because of respiratory distress, and 1 due to difficulty in intubation. CONCLUSIONS The results of this study indicated that surgically securing the airway by tracheostomy should be revised compared to other available methods. In the era of rigid fixation of fractures and the possibility of leaving the patient with an open mouth, it is unnecessary to carry out tracheostomy for securing the airway as frequently as in the past.

Analysis of Complications Following Augmentation With Cancellous Block Allografts

BACKGROUND Bone grafting may be associated with soft and hard tissue complications. Recipient site complications encountered using cancellous block allografts for ridge augmentation are analyzed. METHODS A total of 101 consecutive patients (62 females and 39 males; mean age 44 ± 17 years) were treated with implant-supported restoration of 137 severe atrophic alveolar ridges augmented with cancellous bone-block allografts. Alveolar ridge deficiency locations were classified as anterior maxilla (n = 58); posterior maxilla (n = 32 sinuses); posterior mandible (n = 32); and anterior mandible (n = 15). A total of 271 rough-surface implants were placed. Recipient site complications associated with block grafting (infection, membrane exposure, incision line opening, perforation of mucosa over the grafted bone, partial graft failure, total graft failure, and implant failure) were recorded. RESULTS Partial and total bone-block graft failure occurred in 10 (7%) and 11 (8%) of 137 augmented sites, respectively. Implant failure rate was 12 (4.4%) of 271. Soft tissue complications included membrane exposure (42 [30.7%] of 137); incision line opening (41 [30%] of 137); and perforation of the mucosa over the grafted bone (19 [14%] of 137). Infection of the grafted site occurred in 18 (13%) of 137 bone blocks. Alveolar ridge deficiency location had a statistically significant effect on the outcome of recipient site complications. More complications were noted in the mandible compared to the maxilla. Age and gender had no statistically significant effect. CONCLUSIONS Failures caused by complications were rarely noted in association with cancellous block grafting. The incidence of complications in the mandible was significantly higher. Soft tissue complications do not necessarily result in total loss of cancellous block allograft.

“Mandibular and facial reconstruction” rehabilitation of the head and neck cancer patient

Cancer surgery and its reconstruction today can result in functional and cosmetically supportive results for most patients. Todays better understanding of malignant tumor kinetics has evolved preservative and precision extirpative surgery which has on one hand enhanced cure rates and on the other hand has preserved function and appearance in such patients. Todays reconstructive techniques have a sound basis in wound healing and bone regeneration science so as to be predictable and long lasting. We now consistently reconstruct cancer patients with minimal complications and without adding undue deformity and disability. Within just the past ten years the additional advancement of osseointegrated implants has taken functional results related to chewing force and efficiency to a higher level. These implants provide for an optimal return of eating ability to closely match those with natural dentitions. Such implants have also been taken a step further with their application to facial unit restorations. Today facial units with the excellent tissue color and consistency matches made possible by available elastic materials are worn with confidence and comfort by those who require them. The messy and ineffectual adhesives of the past have been discarded. At the time of this writing the hope for the immediate future is the availability of recombinant human BMP. As the next anticipated advance in complete cancer reconstruction it has the potential to regenerate physiologically normal bone without bone grafting. The reduction in morbidity and operating room time would be an enormous step forward, as would the applicability of reconstruction to more people at a reduced cost.

Pain in the Neck after Neck Dissection

BACKGROUND: Reports of disability after neck dissection have been directed toward shoulder dysfunction and pain. We could find no report addressing the issue of pain localized to the actual operative site. We have conducted a combined prospective and retrospective study of pain in patients undergoing neck dissection. METHODS: Eighty-eight disease-free patients were evaluated in 3 groups for neck pain. One group was followed up prospectively for 1 to 8 months after surgery, and 2 retrospective groups were followed up for more than 2 years or for 6 months to 2 years. Pain was assessed by a body map and visual analog scale. RESULTS: None of 31 patients followed up for more than 2 years reported neck pain. Four of 27 patients followed up for 6 to 24 months had pain, with a mean visual analog scale score of 3.7. Seventy percent of the prospective group of 30 patients had pain during the first postoperative week, and only 1 patient had pain persisting for more than 2 months. Shoulder pain and disability after radical neck dissection were encountered in all groups, comparable with the incidence reported in the literature. No postoperative neuromas were found. CONCLUSIONS: Chronic pain localized to the operative site is an uncommon occurrence even after radical neck dissection. Chronic pain in the shoulder region may follow radical neck dissection, whereas modified neck dissection is usually a painless procedure.

Management of pediatric mandible fractures.

Abstract The pediatric mandible fracture is a rare occurrence when compared with the number of mandible fractures that occur within the adult population. Although the clinician who manages facial fractures may never encounter a pediatric mandible fracture, it is a unique injury that warrants a comprehensive discussion. Because of the unique anatomy, dentition, and growth of the pediatric patient, the management of a pediatric mandible fracture requires true diligence with a variance in treatment ranging from soft diet to open reduction and internal fixation. In addition to the variability in treatment, any trauma to the face of a child requires additional management factors including child abuse issues and long-term sequelae involving skeletal growth, which may affect facial symmetry and occlusion. The following is a review of the incidence, relevant anatomy, clinical and radiographic examination, and treatment modalities for specific fracture types of the pediatric mandible based on the clinical experience at the University of Miami/Jackson Memorial Hospital Oral and Maxillofacial Surgery program. In addition, a review of the literature regarding the management of the pediatric mandible fracture was performed to offer a more comprehensive overview of this unique subset of facial fractures.

Surgical considerations in cases of large mandibular odontomas located in the mandibular angle

The surgical treatment of two large, complex odontomas of the angle of the mandible is described. It is recommended that the surgeon consider excision by an intraoral, lingual approach when indicated. The advantages, indications, and possible complications of this approach are discussed.

The use of ultrasonography as a diagnostic tool for superficial fascial space infections

PURPOSE This study examined the value of ultrasonography as a diagnostic tool in the treatment of superficial acute odontogenic fascial space infections. PATIENTS AND METHODS The study group consisted of 50 patients in whom both radiographic and sonographic examinations, as well as a needle aspiration, were performed. RESULTS Purulent fluid was aspirated in 22 of the 50 patients. Six patients diagnosed as suffering from cellulitis had a repeated ultrasonography scan. In four, abscess formation was diagnosed on the third day. CONCLUSIONS Ultrasonography is an effective diagnostic tool to confirm abscess formation in the superficial fascial spaces and is highly predictable in detecting the stage of infection.