Robert W.T. Myall

Septic arthritis of the temporomandibular joint: review of the literature and report of two cases in children.

Septic arthritis of the temporomandibular joint (TMJ) has a high morbidity, is infrequently reported, and has been described almost exclusively in adults. We present two cases of septic arthritis of the TMJ that occurred in children after minor blunt trauma. Literature related to septic arthritis of the TMJ was reviewed, and a composite list of cases was constructed. The most common causes were various infections of the head and neck, rheumatic joint disease, and iatrogenesis. Pathogens may gain access to the TMJ by several routes. Patients typically present with an acute, tender, monarticular arthritis with associated swelling and erythema. Malaise, nausea, and vomiting may also be present. Traumatic effusions, fractures, and neoplasms may present in a similar fashion, and mimic TMJ septic arthritis. Staphylococcus aureus is the most commonly reported pathogen and often causes permanent joint damage. Aspiration and analysis of joint fluid, as well as blood chemistry, imaging studies, and clinical impression, may assist in the diagnosis. Timely diagnosis and treatment are essential for a successful outcome; therapy should include antimicrobial agents, adequate drainage, and resting of the joint. Complications include spread of infection, postinfectious bony changes, and fibrous (or bony) ankylosis of the temporomandibular joint.

Stability of Le Fort I osteotomy with maxillary advancement: A comparison of combined wire fixation and rigid fixation☆

PURPOSE This study compares two types of fixation: intraosseous wires, skeletal suspension wiring, and maxillomandibular fixation (combined wire fixation; CWF) with rigid internal fixation (RIF) in patients who underwent Le Fort I osteotomy to correct maxillary hypoplasia. MATERIALS AND METHODS All patients were operated on by the same surgeon using a standard technique, which included bone grafting. The 12 patients in group A were treated with CWF for 4 weeks. Group B was made up of 13 patients who had RIF and training elastics for 4 weeks. Cephalometric analysis using a commercial software package was performed on radiographs that were taken immediately preoperatively (T1), 1 day postoperatively (T2), and at least 1 year postoperatively (T4). The position of the maxilla in relation to the cranial base and Frankfort plane at each time interval was compared. RESULTS Postsurgical horizontal change (maxillary position change from T2 to T4) for both groups was in the posterior direction. In group A, six patients had less than 1 mm change, three had 1 to 2 mm change, and three had > 2 mm change. In group B, 10 patients had less than 1 mm change, three had 1 to 2 mm change and 0 had > 2 mm change. Comparison of mean values of groups A and B suggested improved stability with rigid versus wire fixation in the horizontal plane; however, statistical analysis of adjusted mean values showed no significant difference. Vertical changes in maxillary position were also measured from postoperatively to 1 year (T2 to T4). The vertical changes were minimal in those cases of maxillary advancement where no vertical changes were planned; however, there was a statistically significant (P = .0024) improved stability with RIF versus combined wire fixation cases. Comparison of adjusted means showed double the amount of vertical setting 1 year postoperatively in the CWF group. CONCLUSION Overall, 22 of 25 patients with horizontal maxillary advancement had excellent stability at 1 year. Observed trends suggest that RIF may have improved stability over CWF.

Pain following iliac crest bone grafting of alveolar clefts.

The purpose of this study was to investigate pain following iliac crest bone grafting of alveolar clefts. The study involved 34 consecutive patients requiring secondary alveolar bone grafting. The study population consisted of 21 males and 13 females with a mean age of 11 years (SD = 3.4). Twenty-three patients had unilateral and 11 patients bilateral clefts. The patients were treated in a like manner with harvesting of an iliac crest cortico-cancellous block concurrently with the raising of flaps and cleft closure. All surgery was performed by combinations of the authors. Eighteen patients were placed on postoperative intravenous ketorolac and the remainder were not. All patients received patient controlled analgesia at a dose of 0.015 mg/kg of morphine with an 8 min exclusion period before re-dosing. Total narcotic usage averaged 0.18 mg/kg (SD = 0.19) with 31 patients using less than 0.4 mg/kg. Regular ketorolac did not influence narcotic usage, nor did sex, age or nature of the cleft. Thirty-one patients began ambulating on the first postoperative day and 27 were discharged within 2 days of surgery. No long-term donor site morbidity was observed. Our results suggest that pain following iliac crest bone grafting of alveolar clefts is not severe and is readily alleviated with small quantities of analgesic drugs. It would appear that short-term morbidity following these procedures is frequently overstated and is in itself not a valid reason to change to calvarial or mandibular donor sites.

Congenital Bony Syngnathia: A Proposed Classification

Congenital bony syngnathia is an extremely rare condition characterized by bony fusion of the jaws. Five new cases are described and the existent literature is reviewed. A classification system is proposed and treatment recommendations based on this classification are presented.

Orbital abscess of odontogenic origin. Case report and review of the literature

A case is discussed of a patient with an orbital cellulitis and a post septal abscess secondary to infection from an upper molar tooth. Spread of infection was to the maxillary sinus and thence to the orbit via a defect in the orbital floor. The clinical presentation, differential diagnosis, value of CT scanning, treatment and possible complications are reviewed.

A review of Burkitt's lymphoma. Importance of radiographic diagnosis.

Burkitts lymphoma is a malignant proliferation of undifferentiated B lymphocytes that most often affects children. In endemic areas of Africa, the jaws are the sites most frequently involved. In non-endemic areas of North America, the jaws are involved in only 15-18 per cent of the cases. The oral and maxillofacial surgeon can play an important role in the early diagnosis of Burkitts lymphoma by recognizing the clinical signs of multiple loose teeth and jaw tenderness coupled with the radiographic signs of generalized destruction of tooth crypts and diffuse disruption of jaw trabeculation. Successful treatment results from a combination of early diagnosis and controlled chemotherapy.

Condylysis in a patient with a mixed collagen vascular disease.

Condylysis has not previously been described as a complication of a mixed collagen vascular disease. A case is presented in which apertognathia and mandibular retrognathism occurred secondary to condylysis in a 26-year-old woman with features of rheumatoid arthritis, systemic lupus erythematosus, scleroderma, and Sjögrens syndrome. The disease was manifested by polyarthritis, morning stiffnes, subcutaneous nodules, and acrosclerosis. Important laboratory findings included RA slide latex negative, increased DNA binding, ANA positive, ENA negative, and an abnormal parotid scan. The malocclusion secondary to condylysis was corrected by surgical procedures usually employed for the treatment of mandibular retrognathism and apertognathia on a developmental basis.

Melanoma metastatic to the mandible: Report of a case

Metastasis of a tumor to the jaws can simulate an infection, but the presence of paraesthesia and loose teeth or inadequate response to treatment should alert the clinician to a more serious cause. A malignant melanoma metastatic to the jaws illustrates these points.

Intraoral infantile hemangiopericytoma : literature review and addition of a case

A rapidly growing neoplasm in the buccal mucosa of a 4-month-old baby was excised. By light and electron microscopy the neoplasm had features that were similar to those described in infantile hemangiopericytoma, a rare neoplasm of vascular origin. By light microscopy the neoplasm was multilobular with highly proliferating round to spindle-shaped cells interspersed with numerous vascular spaces. Ultrastructurally, round to elongated cells with short processes, pinocytotic vesicles, reduplicated basal lamina, and basal lamina-like material were identified. Immunohistochemically the cells were weakly positive with antibodies to vimentin, focally positive with HHF-35, a smooth-muscle cell antibody, negative with antibodies to S-100 protein, T-200, neuron-specific enolase, neurofilaments, desmin, and cytokeratins 35BH11 and 34BE12. Blood vessels were positive with Ulexeuropaeuslectin, but tumor cells were negative. Reticulin stain decorated a delicate network of fibrils surrounding tumor cells and vascular spaces. Clinically the neoplasm did not recur and the baby has been disease free for more than 26 months. The difficulty of the histologic diagnosis of this neoplasm is discussed and the literature is reviewed, with special emphasis on lesions occurring in the oral cavity.

Chronic factitious illness: Recognition and management of deception

Factitious disease is often manifested in the head and neck region. It is only when the oral and maxillofacial surgeon is aware of the existence of this syndrome and has been unable to correlate a patients history and signs and symptoms with known diseases that factitious illness may be suspected as the diagnosis. Three case histories that help to demonstrate the variety of ruses used by patients to feign illness are presented. The expertise of a psychiatrist will often help to substantiate the diagnosis, but in many instances the main aspects of treatment will remain in the hands of the original clinician. It is important for clinicians to realize that patients with chronic factitious illness are extremely manipulative and unwilling to admit to their fabrications.