Peter D. Quinn

Surgically-assisted rapid palatal expansion for management of transverse maxillary deficiency

An adequate transverse maxillary dimension is a critical component of a stable and functional occlusion.’ Orthopedic rapid palatal expansion in skeletally immature patients is the procedure of choice to correct this condition in that age group. However, as skeletal maturity approaches, bony interdigitation increases as the sutures fuse.2,3 This leads to difficulty separating the maxillas with orthopedic forces alone and bending of the alveolus, dental tipping and minimal maxillary expansion. The result is relapse despite overcorrection, periodontal defects, and malocclusion.4 A variety of surgical procedures including surgically-assisted rapid palatal expansion (SARPE) and segmental LeFort I osteotomies have been advocated in the treatment of transverse maxillary deficiency in skeletally mature patients. The decision to choose one surgical procedure over another has led to some controversy in the literature. The reasoning behind advocating SARPE will be discussed in this article. The isolated transverse maxillary deficiency can be treated either orthodontically or surgically with rapid palatal expansion. However, the long-term stability of the expansion is directly related to the skeletal maturity of the suture lines.5 Krebs6 showed that as sutures mature the majority of orthopedic rapid palatal expansion occurs by dental tipping and alveolar bone bending rather than by skeletal movement. Relapse, with an open bite deformity, may result when fixation is removed.

Biomet Microfixation Temporomandibular Joint Replacement System: A 3-Year Follow-Up Study of Patients Treated During 1995 to 2005

PURPOSE To assess the safety and efficacy of a stock alloplastic total temporomandibular joint (TMJ) implant system, the Biomet Microfixation TMJ Replacement System. MATERIALS AND METHODS During a 10-year multicenter clinical trial from 1995 to 2005, 442 Biomet Microfixation TMJ Replacement Systems were implanted in 288 patients (154 bilaterally and 134 unilaterally). Patients were followed at landmark times, including the date of surgery and at 1 month, 3 months, 1 year, 1 year 6 months, and 3 years. The 3 major metrics that were evaluated were preoperative and postoperative pain, interference with eating, and maximal incisal opening. Paired t tests and comparison analyses were used to assess outcomes. RESULTS There was statistically significant improvement in pain level (P = .0001), jaw function (P = .0001), and incisal opening (P = .0001). Although there were complications necessitating the removal of 14 of 442 implants (3.2%), there were no device-related mechanical failures. CONCLUSIONS The clinical study presented supports the conclusion that a stock TMJ alloplastic replacement, based on sound orthopedic and biomedical principles, is a safe and efficacious option when alloplastic reconstruction of the TMJ is indicated.

Traumatically induced peripheral osteoma: Report of a case

Osteomas of the jaws are well-defined lesions that can present as an isolated finding or as part of a syndrome (e.g., Gardners syndrome). The etiology of peripheral osteomas is somewhat controversial. Trauma has been implicated by several authors, and osteoma is presented here as a rather striking lesion with well-defined traumatic origins.

Single dose and multidose analgesic study of ibuprofen and meclofenamate sodium after third molar surgery

The purpose of this study was to compare the analgesic efficacy and safety of meclofenamate sodium with ibuprofen after dental impaction surgery. This study was double-blind and used a unique methodology. Patients (N = 254) were first randomized into the single dose phase of the study that included placebo, meclofenamate 50 mg, meclofenamate 100 mg, ibuprofen 200 mg, and ibuprofen 400 mg, followed by a 7-day multidose phase in which patients in the placebo group were rerandomized into one of the active treatment cells. In the single dose phase, all active treatments were significantly more efficacious than placebo for every summary analgesic measure. A positive dose-response was seen for both active drugs with meclofenamate 100 mg and ibuprofen 400 mg exhibiting the greatest efficacy for pain relief, pain reduction, time to remedication, and overall evaluation. Side effects were reported by 26 patients. They were evenly distributed among treatment groups with headache and drowsiness being the most common. During the multidose phase, there were only small differences in efficacy measures among active treatment groups. However, meclofenamate produced a higher incidence of stomach cramps and diarrhea than did ibuprofen (8.8% and 7.2% versus 0.8% and 0.8%). This study indicates that higher doses of nonsteroidal anti-inflammatory drugs are most effective immediately after surgery and that lower doses of these drugs can be used after the first postoperative day. The side effect profile of nonsteroidal anti-inflammatory analgesics is best observed with the use of a multidose study design.

Synovial chondromatosis with cranial extension

Synovial chondromatosis is a benign arthropathy characterized by metaplasia in synovial membranes that can produce detached particles of cartilage. It occurs most often in the knee, hip, and elbow but has been reported in the temporomandibular joint. This is a rare presentation of synovial chondromatosis with glenoid fossa erosion and cranial extension.

Facial trismus and myofascial pain associated with infections and malignant disease: Report of five cases

Five cases of facial pain and limited jaw opening, which include two infections, two primary carcinomas, and one metastatic carcinoma, each imitating TMJ dysfunction, are presented. These cases emphasize the importance of (1) a thorough working knowledge of the differential diagnosis of facial pain and limited jaw opening; (2) a complete evaluation, including a review of an adequate medical history as well as a full head and neck examination; and (3) the ability to make use of diagnostic radiographs, including computerized tomography.

Monophasic spindle cell synovial sarcoma of the head and neck: Report of two cases and review of the literature

Synovial sarcoma is a malignant tumor of primitive Report of Cases undifferentiated mesenchymal origin comprising up to 10% of all soft tissue sarcomas.’ The classic histopathologic biphasic synovial sarcoma, consisting of two distinct cell types in varying proportions and patterns, is easily recognized. The epithelial component is composed of cuboidal to columnar cells that commonly form duct-like structures, adjacent to fascicles of spindle-shaped cells with oval nuclei and indistinct cytoplasm. Controversy exists in the literature regarding the presence of a monophasic variety of synovial sarcoma, which fails to display epithelial cells and is composed exclusively of broad sheets of spindle cells. Some pathologists are hesitant to confirm the presence of synovial sarcoma when only one cell type, either spindle or epithelial, is present, because the differential diagnosis of histologically similar tumors is extensive. Mackenzie* states that histologic identification of the biphasic pattern is mandatory in the diagnosis of synovial sarcoma. More recently, however, the monophasic synovial sarcoma, consisting solely of spindle cells, has gained more acceptance as a distinct entity, because positive identification can he documented with the use of immunohistochemical tumor markers. The occurrence of a monophasic variety of synovial sarcoma, either spindle cell or epithelial, in the head and neck is extremely rare, there have heen only four cases reported in the literature,3,4 with three representing metastatic lesions (Table 1). This report presents two cases of primary monophasic spindle cell synovial sarcoma of the head and neck. CASE l* A 28-year-old white man presented with a Cmonth history of right submandibular swelling. He had been treated by a general dentist with incision and drainage and oral antibiotics for a presumed odontogenic infection, without resolution of the mass. The patient complained of slight tenderness of the right neck mass, trismus, and decreased tongue mobility, but denied dyspnea or dysphagia. On physical examination, an 8 X g-cm firm, nonmobile, slightly tender, right anterior cervical neck mass was present. There was no lymphadenopathy. The uvula was deviated to the left, with right palatal draping. A computed tomographic (CT) scan was interpreted as a right submandibular abscess with central necrosis (Fig 1). An incisional biopsy performed through a previous incision and drainage site revealed a poorly differentiated malignant tumor with epithelial features. A metastatic work-up, i’ncluding panendoscopy, bone scan, liver function tests, and head and chest CT scans, was negative.

Magnetic resonance imaging in the diagnosis of trigeminal neuralgia.

Trigeminal neuralgia is not a specific disease, but a symptom elicited by pathology involving the fifth cranial nerve. Advances in the field of magnetic resonance imaging (MRI) have made this the premier imaging modality in the diagnostic workup of trigeminal neuralgia. This article reviews the pertinent anatomy of the trigeminal nerve as well as the structural lesions that produce the symptoms of the condition. The advantages of MRI over other imaging methods are outlined, and the indications for obtaining this study are discussed.

Total Reconstruction of the Temporomandibular Joint with a Stock Prosthesis

Indications for temporomandibular joint (TMJ) reconstruction include bony ankylosis, failed previousalloplasticandautogenousjointreplacement,posttraumaticcondylarinjury,avascularnecrosis, posttumor reconstruction, developmental abnormalities, functional deformity, and severe inflammatory conditionsthathavefailedtoresolvewithconservativetreatments.SuccessfulTMJreplacementrequires careful preoperative planning, reasonable patient expectations, proper intraoperative technique, regimented postoperative physical therapy, close follow-up, and adequate pain management. Achieving successful TMJ replacementoftenrequires multidisciplinary care from oral and maxillofacial surgeons, pain specialists, internists, physical therapists, and general dentists to optimize patient outcome. Alloplastic joint reconstruction currently offers several advantages compared with autogenous replacements. These advantages include lack of donor morbidity, reduced intraoperative surgical time, immediate functioning, the ability to correct malocclusion (with bilateral replacement), and, most importantly, improved predictability. The most widely used autogenous graft for TMJ reconstruction is the costochondral graft. Compared with alloplastic joint reconstruction, costochondral grafting has a higher complication rate. Complications include graft resorption, overgrowth, and ankylosis. Alloplastic joint reconstruction allows for a stable platform in which retrognathia and facial asymmetry may be corrected in a single surgical procedure. Unacceptable failure rates have been reported in previous alloplastic TMJ implant systems, which haveprovidedvaluableinputforthedevelopmentofnewerimplantsapprovedbytheUSFoodandDrug Administration (FDA). Appreciation of biomechanical and orthopedic principals, along with appropriate clinical trials, has helped in the development of safe and effective devices. These devices still have limitations, such as finite life expectancy, limited translation, the development of wear debris, and the size of the devices. Because fewer patients are requiring revision arthroplasty from previous faileddevices,itcanbeexpectedthatmoreprimaryjointreconstructionwillbeperformedforconditions such as severe inflammatory arthritides, trauma, and ankylosis. A stock prosthetic device has the advantagesofimmediateavailability,single-stagesurgery,noneedforrecapitulationfromastereolithic model, and lower cost. Contraindications to alloplastic joint placement include the presence of active infection, skeletal immaturity, and severe or compromised bone deformity. Patients with severe bone anatomic discrepancies may be candidates for patient-matched custom implants.

Total temporomandibular joint reconstruction with a Delrin titanium implant.

Numerous alloplastic materials have been used for partial or total reconstruction of the temporomandibular joint in patients with fibrous or bony ankylosis, severe degenerative joint disease, or traumatic deformity, and for reconstruction following tumor resection and corrective surgery following multiple arthroplasties. We have had initial success with the use of a polyoxymethylene (Delrin) condylar head affixed to a pure titanium mesh for these reconstructive procedures. This versatile prosthesis does not require use of a separate glenoid fossa prosthesis. The surgical technique, as well as a historical perspective on alloplastic total joint prostheses used to date, is described in several patients.