Michael Rasse

Clinical manifestations and diagnostic approach to metastatic cancer of the mandible

In a 12-month period, metastatic cancer was diagnosed in eight patients. Six of them presented with pain mimicking toothache, temporomandibular joint disorders or trigeminal neuralgia, while two showed osteopenic bone lesions in the panoramic radiography, and perimandibular swelling. Anesthesia of the lower lip was the only common clinical feature. In seven of the eight patients, a whole body bone scintigraphy and single photon emission computed tomography (SPECT) of the skull in combination with a whole body and SPECT anti-granulocyte (Tc-99m MAK 250/183) bone marrow scintigraphy was performed. One patient did not have combined scintigraphy performed secondary to severe systemic illness. In six of the seven, the results were conclusive for a metastatic bone lesion. Biopsies confirmed three patients to have a previously unrecognized primary cancer, one patient to have previously unrecognized recurrent cancer, and three patients to exhibit new metastatic spread of an already diagnosed cancer. Histology revealed breast, lung, renal cancer and a malignancy of inconclusive origin. In the remaining patient, combined scintigraphy suggested osteomyelitis, yet biopsy revealed a prostate cancer metastasis with acute inflammatory cell infiltration. Thus, the scintigraphy pattern of a hot spot in the bone scan and a cold lesion in the bone marrow scintigraphy is highly suggestive of a mandibular metastasis, if accompanied by anesthesia of the lower lip.

Transoral miniplate osteosynthesis of condylar neck fractures

OBJECTIVE In a retrospective study, we reviewed a series of 55 consecutive patients with 57 fractures of the condylar neck that were treated with transoral miniplate osteosynthesis. STUDY DESIGN Forty-one patients were included in a clinical follow-up study; the median length of study was 26.5 months (minimum, 7 months; maximum, 79 months). In a radiographic study, the positions of the condyle before open reduction, after open reduction, and more than 6 months postoperatively were evaluated in 3 radiographic planes. A statistical analysis was performed to determine factors that lead to secondary instability of the reduced condyle and to correlate the actual position of the condyle with clinical parameters collected in follow-up examinations. RESULTS At the time of the follow-up examination, the median measurement of the mandibular openings was 48.3 +/- 8.0 mm (minimum, 32 mm; maximum, 66 mm). A deviation of 2 mm to the operated side when opening was observed in 7 patients. The median range of laterotrusion was 10.0 mm to the fracture side and 9. 0 mm to the opposite side. In 7 patients, radiographic follow-up more than 6 months postoperatively revealed a medial tilt of the proximal fragment of 15 to 40 degrees despite a good immediate postoperative position of the condyle. This may be attributed to bone resorption in the fracture gap, together with a bending instability observed when titanium miniplates with a thickness of 0. 9 mm were used. The position of the condyle at the follow-up examination did not correlate with clinical parameters. CONCLUSIONS Transoral approach miniplate osteosynthesis of dislocated condylar neck fractures is indicated when visible scars in the head and neck region, which are encountered with other fixation techniques, must be avoided.

Surgical reduction and fixation of intracapsular condylar fractures: A follow up study

Controversies still exist about the preferred treatment of condylar head and neck fractures. Newly developed access techniques in combination with new methods to fix the fragments, lead to satisfactory results. This study deals with a refinement of surgical treatment of intracapsular fractures.

Treatment of recurrent mandibular dislocation, part II : Eminectomy

Fourteen patients underwent eminectomy for recurrent mandibular dislocation. The clinical follow-up period ranged from 7 months to 5 years. The function of the temporomandibular joint before and after eminectomy was analysed clinically and by computer-aided axiography. There was no significant decrease in the condylar path angle postoperatively, though the articular eminence had been removed up to its most medial portion. Translatory border movements showed significant limitation six months after surgery and normal range of motion in the first and second year after the operation. Postoperative hypermobility of the condyle was not observed.

Treatment of recurrent mandibular dislocation, part I: Leclerc blocking procedure

Nine patients with recurrent mandibular dislocation, who underwent the blocking procedure of Leclerc and Girard, as modified by Gosserez and Dautrey, are presented. The follow-up period range from 2.5 to 5 years. An axiographic study revealed significant postoperative limitation of translation of the condyle when opening, while maximal mouth opening as measured between the incisors, as well as translation of the condyle in protrusion and mediotrusion, showed no significant limitation. Long-term evaluation showed a high incidence of clicking and pain, not evident prior to surgery. The causes for recurrence in three cases were analysed.

Neurofibromatosis 1: A novel NF1 mutation in an 11-year-old girl with a giant cell granuloma

We report an 11-year-old girl who presented with a painless unilateral enlargement of the nasal bridge. Because of multiple café-aulait spots and a positive family history, neurofibromatosis 1 was diagnosed. On a computed tomographic scan, a unilocular radiolucency measuring 1.2 × 2 cm was seen in the anterior wall of the maxillary sinus, which was surgically removed. Histology revealed a central giant cell granuloma. Hyperparathyroidism, which can present with an osseous tumor and similar histology, was excluded. Molecular analysis uncovered a novel splice mutation (A4268G) in this neurofibromatosis 1 family, affecting our patient as well as her mother and brother. This article focuses on the variability of the neurofibromatosis 1 phenotype in this family and the possible relationship between central giant cell granuloma and neurofibromatosis 1. (J Child Neurol 2003;18:371—373).

Clinical experience with interactive teleconsultation and teleassistance in craniomaxillofacial surgical procedures

PURPOSE The objective of this study was to evaluate the clinical value and feasibility of surgical telenavigation and teleassistance technology in the field of craniomaxillofacial surgery. MATERIALS AND METHODS The technology is based on the principles of augmented reality environment technology and remote stereotactic visualization. A consultant surgeon in a remote location receives video, audio, and stereotactic navigation data from the operation site almost in real-time and, using a head-mounted display, is emerged in the surgical augmented reality environment. By telepresence or teleconsultation, the composite images and superimposed graphics (instruments, target structures, landmarks, contours) can be seen and discussed in connected clinics with the possibility of interactive manipulation and assistance. RESULTS Interactive teleassistance was used in 27 cases of various types craniomaxillofacial surgery. The principles of computer-aided telenavigation were applied successfully. Technical problems in 6 cases did not cause a breakdown of overall system performance. CONCLUSION Teleconsultation with remote experts is a useful tool, although some shortcomings exist. The financial and personal effort involved is considerable.

Recurrent mandibular dislocation under neuroleptic drug therapy, treated by bilateral eminectomy

Acute mandibular dislocations caused by extrapyramidal syndromes under neuroleptic therapy have often been reported in the literature. However, the success of surgical therapy for recurrent mandibular dislocation in patients under long-term neuroleptic therapy has been discussed controversially. In our opinion, modifications in drug therapy--including the administration of so-called atypical neuroleptics--should be considered before advocating surgery. If the revised therapeutic approach proves to be unsuccessful because of psychotic relapse or persistence of extrapyramidal symptoms, good operative results may be achieved by bilateral eminectomy as reported on three psychiatric patients in this paper. In order to avoid postoperative subluxation and internal derangement due to increased muscular tension under chronic neuroleptic therapy, as much bone as possible should be removed when performing eminectomy.

Cartilaginous exostoses of the mandible

Although cartilaginous exostosis is considered to be the most common tumor of the skeleton, it is relatively uncommon in the jaws. The pathogenesis of the lesion is unclear. Three cases are presented and the development of the tumors from embryonic cartilage is discussed.

Modifikationen des Zugangs zum Kiefergelenk und Ramus mandibulae

ZusammenfassungHintergrundVon 1990 bis 1991 wurden an der Klinik für Kiefer- und Gesichtschirurgie in Wien 118 Operationen am Kiefergelenk ausgeführt. Es wurden dabei bekannte Zugänge nach den klinischen Erfordernissen modifiziert. Der Zugang sollte den Nervus facialis, auriculotemporalis und auricularis magnus schonen, die Muskulatur möglichst erhalten und keine sichtbaren Narben hinterlassen.Methode1. Aurikulärer Zugang: Die Inzision folgt den entwicklungsge-schichtlichen Grenzen zwischen 1. und 2. Branchialbogen und berücksichtigt somit Gefäß- und Nervenversorgung der Ohrmuschel. Zur Schonung der temporalen Facialisäste wird subperiostal und subfaszial präpariert. 2. Submandibulärer Zugang: Es wird ein Wechselschnitt verwendet und die Äste des Nervus facialis dargestellt.ErbebnisseDie Äste des Nervus facialis konnten immer geschont werden (elektroneurographische Kontrolle). Die sensible Versorgung blieb erhalten.SchlußfolgerungDie beschriebenen modifizierten Operationszugänge ermöglichen eine optimale Exposition der temporo-mandibulären Gelenksregion oder des Ramus mandibulae bei maximaler Schonung gefährdeter Nerven und optimalen kosmetischen Ergebnissen.SummaryBackgroundFrom 1990 to 1991, 118 operations on the temporomandibular joint were performed at the Clinic for Maxillo-Facial Surgery of the University of Vienna. This experience has lead to modifications to better meet the requirements for saving facial nerve, auriculotemporal nerve and great auricular nerve and the muscles, as well as for scars as invisible as possible.MethodAuricular access: The incision line follows the border of the first and second branchial arches, thus taking into account the nerve and blood supply of the region. To save the facial nerve subperiosteal and subfascial dissection is employed.Submandibular access: A gridiron incision is used to save the platysma and masseter muscle. The branches of the facial nerve are exposed.ResultsElectroneurography showed preservation of the facial nerve. Sensibility was preserved.ConclusionThe described modifications of the access to the temporo-mandibular joint or to the mandibular ramus allow an optimal exposition by saving endangered nerves and excellent cosmetic results.