Pushkar Mehra

Maxillary sinus disease of odontogenic origin

Odontogenic sinusitis is a well-recognized condition and accounts for approximately 10% to 12% of cases of maxillary sinusitis. An odontogenic source should be considered in patients with symptoms of maxillary sinusitis who give a history positive for odontogenic infection or dentoalveolar surgery or who are resistant to standard sinusitis therapy. Diagnosis usually requires a thorough dental and clinical evaluation with appropriate radiographs. Common causes of odontogenic sinusitis include dental abscesses and periodontal disease perforating the Schneidarian membrane, sinus perforations during tooth extraction, or irritation and secondary infection caused by intra-antral foreign bodies. The typical odontogenic infection is now considered to be a mixed aerobic-anaerobic infection, with the latter outnumbering the aerobic species involved. Most common organisms include anaerobic streptococci, Bacteroides, Proteus, and Coliform bacilli. Typical treatment of atraumatic odontogenic sinusitis is a 3- to 4- week trial of antibiotic therapy with adequate oral and sinus flora coverage. When indicated, surgical removal of the offending odontogenic foreign body (primary or delayed) or treatment of the odontogenic pathologic conditions combined with medical therapy is usually sufficient to cause resolution of symptoms. If an oroantral communication is suspected, prompt surgical management is recommended to reduce the likelihood of causing chronic sinus disease.

Management of heparin therapy in the high-risk, chronically anticoagulated, oral surgery patient: A review and a proposed nomogram

PURPOSE This study analyzes the use of a standard nomogram that can help reduce the level of anticoagulation preoperatively to effectively manage perioperative heparin therapy in chronically anticoagulated oral surgery patients who are at high risk for thromboembolism. PATIENTS AND METHODS Twenty patients with significant cardiovascular disease, ranging in age from 56 to 79 years and requiring oral surgery, were randomly divided into 2 groups. All patients were on chronic warfarin therapy, and perioperative heparinization was recommended by their cardiologist. Group A (n = 10) had their anticoagulation therapy managed with the use of a standard nomogram. The heparin therapy for group B (n = 10) was managed without the use of the nomogram. The records of all patients were analyzed for therapeutic efficacy of heparinization, number of laboratory tests required, duration of hospitalization, and complications related to heparinization. RESULTS Patients in group A did significantly better in all parameters when compared with group B patients. There were no complications in group A, whereas there was a 20% incidence of complications related to anticoagulation therapy in group B. CONCLUSIONS The use of a standard nomogram to manage anticoagulation therapy in the oral surgery patient requiring heparinization is strongly recommended. This provides optimal therapeutic benefit, decreases the incidence of complications, and makes the hospitalization less costly and more comfortable for the patient.

Life-threatening, delayed epistaxis after surgically assisted rapid palatal expansion: A case report

Lutcavage GJ: Traumatic facial artery aneurysm and arteriovenous fistula: Case report. J Oral Maxillofac Surg 50:402, 1992 Wineland PL, Topazian RG, Marble HB Jr: False aneurysm of the facial artery. J Oral Surg 34:642, 1976 Akker HP van den, Lijn F van der: A false aneurysm of the facial artery as a complication of circumferential wiring. Oral Surg Oral Med Oral Path01 37:514,1974 Schwartz SH, Blankenship BJ, Stout RA: False aneurysm of the facial artery: Report of case. J Oral Surg 29:672,1971 Bresner M, Brekke J, Dubit J, et al: False aneurysm of the facial region. J Oral Surg 30:307, 1972 Cohen SM: Vascular surgery and reticuloendothelium system, in Rob C, Smith R (eds): Clinical Surgery, vol 14. Philadelphia, PA, Lippincott, 1967, pp 140-141 Schwartz HC, Kendrick RW, Pogrel BS: False aneurysm of the matiary artery: An unusual complication of closed facial trauma. Arch Otolaryngol109:616, 1983 Cohen MA: False (traumatic) aneurysm of the facial artery caused by a foreign body. Int J Oral Maxillofac Surg 15:336, 1986 Kennedy JW, Kent JN: False aneurysm and a partial facial paralysis secondary to mandibuiar fracture: Report of case. J Oral Surg 28:854, 1970 Taylor DV: Traumatic aneurysm and facial palsy as complication of a mandibular fracture. Br J Oral Surg 4:202, 1967 Calem WS: Traumatic (false) aneurysm of the terminal portion of the external carotid artery. Am J Surg 106:522, 1963 Wagner M: Pseudoaneurysm. A complication of percutaneous angiography and angiocardiography. JAMA 186:427, 1963 Derdeyn CP, Moran CJ, Cross DT, et al: Intraoperative digital subtraction angiography: a review of 112 consecutive examinations. AJNR 16:307, 1995 Heiserman JE, Dean BL, Hodak JA, et al: Neurologic complications of cerebral angiography. AJNR 15:1401, 1994

Use of 3-D Stereolithographic Models in Oral and Maxillofacial Surgery

ObjectiveTo assess the feasibility of the use of 3-dimensional (3-D) stereolithographic (SLA) technology in complex maxillofacial reconstructive surgery.Materials and Methods3-D SLA technology was used in the treatment planning of complex maxillofacial procedures performed by the Department of Oral and Maxillofacial Surgery at Boston University. Specialized 3-D models were ordered and utilized for surgical treatment of a variety of indications including trauma surgery, temporomandibular joint surgery, orthognathic surgery, secondary correction of facial and skull deformities, and extensive jaw pathology. This technology was also used in one patient for jaw reconstruction using novel bone and tissue engineering techniques.ResultsThe use of 3-D models in Oral and Maxillofacial Surgery significantly improved predictability of clinical outcomes when compared to similar treatments without its use. Total operating time was reduced which had the benefit of decreasing the duration of general anesthesia and reducing wound exposure time. They allowed for assessment of extensive traumatic and pathologic defects in three-dimensions prior to surgical reconstruction. The models were also useful in the design and fabrication of custom prostheses, sizing of bone grafts and allowed for manufacturing of scaffolds for bone regeneration.Conclusions3-D SLA models can be very effectively used in oral and maxillofacial surgery for multiple indications and diverse clinical scenarios. Successful incorporation of this technology for jaw bone regeneration using tissue engineering techniques offers exciting new prospects for the future.

Internal Fixation of Mandibular Angle Fractures: A Comparison of 2 Techniques

PURPOSE To compare treatment outcomes between rigid extraoral fixation and semirigid intraoral fixation for the management of isolated mandibular angle fractures, and to develop a protocol for successfully managing these fractures in an indigent population. MATERIALS AND METHODS This study involved a retrospective analysis of mandibular angle fracture patients treated at Boston Medical Center from 1999 to 2006. All patients were treated by a single attending surgeon, with oral and maxillofacial surgery residents. Data were collected by a review of pertinent inpatient and outpatient clinic records, and radiographic and laboratory results. The criteria for inclusion into the study comprised: 1) patients with isolated unilateral or bilateral mandibular angle fractures; 2) surgical treatment provided within 7 days of injury via 1 of the 2 following techniques: a) open reduction and internal fixation via an intraoral approach (single monocortical miniplate), or b) open reduction and internal fixation (ORIF) via an extraoral approach (inferior border plate with at least 2 holes on either side of the fracture line and bicortical screws); 3) the presence of decayed, partially bony, or full bony impacted third molars requiring removal at time of surgery; 4) the use of postsurgical maxillomandibular fixation (MMF) for 1 week (extraoral rigid-fixation cases) and 2 weeks (intraoral semirigid-fixation cases) and 5) a 1-week duration of postsurgical oral antibiotic therapy. RESULTS The patient sample ranged in age from 17 to 55 years, with an average age of 24.8 years. The average follow-up was 12.3 weeks (range, 8 to 64 weeks). In total, 98 fractures were treated with intraoral miniplate fixation, whereas 65 fractures underwent rigid fixation using an extraoral approach. The presence or absence of bone gaps in radiographs immediately after surgery had no correlation with surgical success. None of the patients in either group required further surgical intervention in the operating room. Patients with postsurgical infections were successfully managed with localized intraoral incision and drainage, and oral antibiotic therapy. CONCLUSION Isolated mandibular angle fractures can be effectively treated in an indigent population with either intraoral monocortical fixation or extraoral bicortical fixation techniques. Use of a standard protocol involving early surgical management with limited periosteal reflection, concomitant removal of third molars, and short-term maxillomandibular fixation ensures predictable success with a low incidence of complications.

Single-stage comprehensive surgical treatment of the rheumatoid arthritis temporomandibular joint patient.

PURPOSE To prospectively evaluate the outcomes of single-stage reconstruction of patients with rheumatoid arthritis (RA) with temporomandibular joint (TMJ) pathologic features and an associated dentofacial deformity. PATIENTS AND METHODS Fifteen patients (12 females, 3 males) with RA underwent TMJ reconstruction, with or without a Le Fort I osteotomy in a single operation. Clinical and radiographic examinations were performed before surgery, immediately after surgery, and at the longest follow-up intervals. Numeric analog scales were used for subjective evaluation of TMJ pain, jaw function, diet, and disability. The maximal interincisal opening, lateral excursions, and TMJ crepitus were recorded at each visit. Standardized cephalometric acetate tracings were superimposed to assess for surgical (immediately after surgery compared with before surgery) and postoperative (longest follow-up interval compared with immediately after surgery) changes. RESULTS The average patient age was 27.4 years (range 15 to 61), and the follow-up was 34.3 months (range 10 to 77). At the longest follow-up interval, all 15 patients had had a statistically significant reduction in the incidence and severity of TMJ pain and headaches. The average maximal interincisal opening increased after surgery, but the difference was not statistically significant. Lateral excursions decreased significantly after surgery. Dietary restrictions and disability were significantly improved, and TMJ crepitus had reduced significantly. The average advancement at point B was 21.7 mm (range 14 to 28), and the postoperative change at the longest follow-up interval was 0.1 mm (range 0 to 1). The average pogonion advancement was 29.2 mm (range 19.5 to 38), with a postoperative change of 0.2 mm (range 0 to 1). The average gonion vertical lengthening was 20.7 mm (range 10.5 to 29) with a postoperative change of 1.4 mm (range 0 to 4.5). The average occlusal plane angle change was a decrease of 20.7 degrees (range 16 degrees to 26 degrees), with a postoperative change of 0.4 degrees (range 0 degrees to 2 degrees). Of the 15 patients, 10 had undergone maxillary orthognathic surgery performed at the same operation. The average advancement of these 10 patients at point A was 3 mm (range 2 to 7), and the postoperative change was 0.5 mm (range 0 to 1). CONCLUSIONS Surgical correction of rheumatoid-associated TMJ disease and the resulting dentofacial deformity can successfully be performed in a single operation using custom-made TMJ total joint prostheses to reconstruct the TMJs and advance the mandible, with maxillary orthognathic surgery and genioplasty performed at the same operation when indicated. The significant reduction in TMJ dysfunction symptoms and the long-term stability of the orthognathic surgery movements show the benefits and predictability of treating these complex patients with this treatment protocol.

Surgical management of obstructive sleep apnea

Obstructive sleep apnea (OSA) syndrome is a common disorder that has recently received much attention by the medical community due to its potentially serious physiological consequences. The clinical significance of OSA results from hypoxemia and sleep fragmentation caused by collapse of the airway, which leads to apnea or hypopnea during sleep. This paper reviews common surgical techniques used for clinical management of OSA patients, with emphasis on jaw advancement surgical procedures.

Use of the Mitek anchor in temporomandibular joint disc-repositioning surgery.

The temporomandibular joint (TMJ) is a bilateral diarthrodial joint of the jaws in the human skeleton. This unique joint can perform both hinge and sliding functions and is the only synovial joint in humans whose articulating surfaces are covered by fibrocartilage. The joint is formed by the bony articulations of the mandibular condyle and the temporal bone (glenoid fossa and articular eminence). Interposed between the condyle and the fossa is a piece of dense, avascular fibrous connective tissue, the TMJ articular disc. This disc divides the joint into superior and inferior joint compartments, which normally do not communicate with each other. The disc and condyle are in a normal anatomic relationship if the posterior band of the disc is located above the condylar head when the mandibular condyle is centrically positioned in the fossa (Figure 1a). The disc is attached to the condylar neck by ligamentous soft tissue attachments. The joint is circumferentially surrounded by a fibrous capsule and has

Custom-made total joint prostheses for temporomandibular joint reconstruction.

Jaw joint (temporomandibular joint or TMJ) disease is estimated to affect 30 million Americans, with approximately 1 million new patients diagnosed each year (1). Although many of these patients can be managed with nonsurgical therapies, some patients require surgical intervention. The TMJ is a unique joint in that it does not function independently but works in tandem with its contralateral joint. Therefore, disease affecting 1 joint can either directly or indirectly affect the functioning and health of the contralateral joint. When surgical intervention of the TMJ is required, the joint can often be reconstructed with autogenous tissues. However, certain TMJ conditions and pathology require reconstruction with a total joint prosthesis for predictable treatment outcomes. Some of these conditions include ≥2 previous TMJ surgeries; previous TMJ alloplastic implants containing Proplast/ Teflon (PT), Silastic, acrylic, or bone cements; inflammatory or resorptive TMJ pathology; connective tissue or autoimmune disease (i.e., rheumatoid arthritis, psoriatic arthritis, scleroderma, Sjogrens syndrome, lupus, and ankylosing spondylitis); fibrous or bony ankylosis; absence of TMJ structures due to pathology, trauma, or congenital deformity; and tumors involving the condyle and mandibular ramus area. Currently, the only TMJ total joint prosthesis approved by the Food and Drug Administration (FDA) is the custom-made device manufactured by TMJ Concepts, Inc. (Camarillo, Calif). The device was manufactured by the same company under the name Techmedica, Inc. from 1989 to 1993.

Rigid internal fixation of infected mandibular fractures.

PURPOSE To evaluate the treatment outcomes of rigid internal fixation for the management of infected mandible fractures. PATIENTS AND METHODS A retrospective chart review of infected mandible fractures managed by a single oral and maxillofacial surgeon at a level I trauma center during a 7-year period was accomplished by independent examiners. All patients were treated with incision and drainage, culture and sensitivity testing, extraction of nonsalvageable teeth, placement of maxillomandibular fixation when possible, fracture reduction with bone debridement and decortication, rigid internal fixation of the mandible by an extraoral approach, and antibiotic therapy. The medical and social history was contributory in most patients. The analysis was stratified by the differentiation of the fractures into 2 groups: those with soft tissue infections in the fracture region versus those with hard tissue-infected fractures (biopsy-proven osteomyelitis). RESULTS A total of 44 patients were included in this study, with an average follow-up of 18.2 months from the date of surgery (range 3 to 48). The treatment protocol was successful in all 18 patients (100%) with soft tissue infected mandibular fractures and 24 (92%) of 26 patients with hard tissue-infected fractures. CONCLUSIONS A protocol consisting of concomitant incision and drainage, mandibular debridement, fracture reduction, and stabilization with rigid internal fixation can be effectively used for single-stage management of infected mandible fractures.