Thomas Schlieve

Temporomandibular Joint Replacement for Ankylosis Correction in Nager Syndrome: Case Report and Review of the Literature

p o l i a Nager acrofacial dysostosis is a mandibulofacial abnormality characterized by downward slanting of the palpebral fissures, malar hypoplasia, bilateral conductive hearing loss, cleft palate, micrognathia, absent or hypoplastic thumbs, and radial limb hypoplasia. The syndrome shares many phenotypic features with Treacher-Collins syndrome; however, it is recognized as a separate clinical entity. A comprehensive review of the published data regarding Nager syndrome was completed to better understand the syndrome itself and the multiple treatment modalities historically used for correction of the variety of clinical manifestations, including mandibular retrognathism. In addition, we present the 94th reported case of Nager syndrome and the correction of bilateral temporomandibular joint (TMJ) ankylosis, resulting from multiple failed previous mandibular surgeries, with bilateral custom total TMJ prosthetic replacement. Nager syndrome, also known as Nager acrofacial dysostosis, was first described and distinguished from other acrofacial disorders in 1948 by Nager and Derenier. It is a genetic craniofacial disorder with varying opinions regarding its etiology, thereby suggesting a possible heterogeneous pathogenesis. An

Is Immediate Reconstruction of the Mandible With Nonvascularized Bone Graft Following Resection of Benign Pathology a Viable Treatment Option

PURPOSE The purpose of this study was to address the following clinical question: Is immediate reconstruction of the mandible with a nonvascularized bone graft after resection of benign pathology a viable treatment option? Another purpose was to determine whether any variables affect the success of this treatment approach. MATERIALS AND METHODS The authors implemented a retrospective cohort study from a sample of patients diagnosed with a benign tumor of the mandible who were treated with segmental resection and primary reconstruction with an autogenous nonvascularized bone graft. The predictor variables were age, gender, lesion size, and diagnosis, and the outcome variable was graft success determined by re-establishment of mandibular continuity with sufficient bone for implant placement. The χ(2) test was used for statistical analysis of the categorical data and P values less than .05 were considered statistically significant. RESULTS Twenty patients with benign mandibular tumors were treated with transoral resection and immediate reconstruction with nonvascularized bone grafts. The mean age was 28.3 years (range, 9 to 63 yr) and 55% (11 of 20) were men. The most common lesion type was ameloblastoma (13 of 20) and all patients underwent reconstruction with autogenous anterior iliac crest bone grafting. Ninety percent of patients (18 of 20) had successful reconstruction. Ten patients underwent successful implant placement and restoration. CONCLUSIONS Using careful patient selection, treatment of benign pathology with transoral resection and immediate reconstruction with a nonvascularized bone graft from the anterior iliac crest can be successful. In addition, the total treatment time from implant restoration to return to preoperative function is minimized. Therefore, this method of treatment is a viable treatment option and an alternative to delayed reconstruction or reconstruction with vascularized bone flaps.

Simple Method for Securing a Decompression Tube for Odontogenic Cysts and Tumors: A Technical Note

Decompression of odontogenic cysts and certain odontogenic tumors is a straightforward procedure used very commonly in the treatment of these entities. The goals for use of the decompression technique are usually determined by the size, location, and type of the pathology encountered. The most common reason for incorporating the decompression technique in the treatment algorithm for an odontogenic entity is the keratocystic odontogenic tumor. Several “decompression tubes” have been described and successfully used for this purpose. Some of the common problems encountered during the course of this type of treatment, which is extended over several months, originate from the size of the decompression tube itself and/or the trauma to the soft tissues from resorbable or nonresorbable sutures, or malposition or dislodgment of the tube. Although these are not major complications, they contribute to the discomfort and inconvenience for the patient and the clinician. The aim of this technical note is to describe a straightforward way of securing a polyethylene tube, commonly used for decompression, to minimize the trauma to the surrounding soft tissues, and to maximize retention in the proper location and position in relation to the cyst or tumor. Twenty-two patients were treated with this approach at our institution. The technique involves using a 28-gauge stainless steel ligature wire that secures the tube around the tooth/teeth immediately adjacent to the site of the lesion. In this manner, the soft tissues around the tube are not traumatized from any suture material or tube displacement because the position is secured with a wire, and adequate oral hygiene can be performed easily. Additionally, tube length adjustments may be required often during the treatment course, and these may be performed in a noninvasive fashion, and without the need for ad

Does decompression of odontogenic cysts and cystlike lesions change the histologic diagnosis

PURPOSE The purpose of this study was to report the histopathologic findings after postdecompression definitive treatment of odontogenic cystlike lesions and determine whether the diagnosis was consistent with the pretreatment diagnosis, thereby answering the clinical question: does decompression change the histologic diagnosis? MATERIALS AND METHODS The authors implemented a retrospective cohort study from a sample of patients diagnosed with a benign odontogenic cystlike lesion and who underwent decompression followed by definitive surgery as part of their treatment. The predictor variable was treatment by decompression and the dependent variable was change in histologic diagnosis. Age, gender, and lesion location were included as variables. The χ(2) test was used for statistical analysis of the categorical data and P values less than .05 were considered statistically significant. RESULTS Twenty-five cysts and cystlike lesions in 25 patients were treated with decompression followed by enucleation and curettage. The mean age was 34 years (range, 13 to 80 yr) and 56% (14) were male patients. Lesions were located in the mandible in 76% (19 of 25) of patients. Postdecompression histologic examination at the time of definitive surgical treatment was consistent with the preoperative biopsy diagnosis in 91% (10 of 11) of keratocystic odontogenic tumors, 67% (2 of 3) of glandular odontogenic cysts, 75% (3 of 4) of dentigerous cysts, and 100% (7 of 7) of cystic ameloblastomas. CONCLUSIONS The histologic diagnosis at time of definitive treatment by enucleation and curettage is consistent with the predecompression diagnosis. Therefore, all lesions should be definitively treated after decompression based on the initial lesion diagnosis, with all patients placed on appropriate follow-up protocols.

Squamous cell carcinoma of the oral tongue: histopathological parameters associated with outcome.

The purpose of this study was to investigate the applicability of the histological risk assessment model proposed by Brandwein-Gensler et al. in a cohort of oral tongue squamous cell carcinoma (OTSCC) patients treated with definitive surgery. We also examined the impact of additional histopathological features on disease acceleration. The cases of 49 OTSCC patients attending our institution between 1995 and 2009, who underwent definitive surgical resection followed by adjunct chemoradiotherapy when indicated, were reviewed retrospectively. Surgical resection specimens and complete clinical and demographic data were available for these patients; follow-up was at least 6 months. In this cohort we only identified a correlation between gender and the histopathological risk model score (P<0.001). With regard to clinical and demographic data, histopathological parameters, and disease status at last follow-up, we identified significant correlations between disease status and (1) grade of differentiation (P=0.0086), and (2) keratin score (P=0.026). We found no significant correlations between the histopathological risk assessment model and disease progression or outcomes, with the exception of gender (P<0.0001). Grade of differentiation, keratin score, and the lymphocytic host response significantly impacted disease acceleration. For OTSCC, it appears that clinical characteristics of the tumour as well as histopathological markers play an important role in the outcome. Efforts towards identifying predictive markers should be continued, especially by sub-site of the oral cavity.

External Reference Nasal Pin for Orthognathic Maxillary Positioning: What Is the Proper Method of Placement?

PURPOSE Intracranial perforation with an external reference nasal pin is a possible complication during maxillary orthognathic surgery. This study attempts to quantify the maximum allowable depth of pin penetration from the soft tissue nasion (STN) and hard tissue nasion (HTN) to the anterior cranial fossa (ACF) and to evaluate the depth and direction of the nasal pin track using postsurgical cone-beam computed tomography (CBCT). MATERIALS AND METHODS Two groups of patients were evaluated. A retrospective cross-sectional chart review evaluated the distance from the STN and HTN to the ACF from random patients on CBCT scans. In addition, a different group of postsurgical orthognathic cases treated between March 2013 and August 2015 were analyzed for the depth and direction of the nasal pin track toward the next anatomic cavity, which included the ACF, frontal sinus, or nasal cavity. RESULTS We identified 103 random patients, aged 14 to 90 years. The mean distance from the STN to the ACF was 21.85 mm (range, 14.06 to 29.12 mm), and the mean distance from the HTN to the ACF was 14.16 mm (range, 7.35 to 20.53 mm). Forty postsurgical CBCT scans showed an overall nasal pin track depth of 12.91 mm (range, 8.53 to 22.60 mm), with the direction of the pin track toward the nasal cavity in most cases. CONCLUSIONS The depth of penetration of an external reference nasal pin should be limited to a maximum of 10 to 12 mm from the STN. Initial skin penetration should begin immediately caudal to the STN, and the pin should be directed in a caudal direction to avoid inadvertent entrance into the ACF, as well as to facilitate a relatively safe penetration into the nasal cavity, if the maximum depth is excessive.

How do general dentists and orthodontists determine where to refer patients requiring oral and maxillofacial surgical procedures

PURPOSE This study investigated the influence of specific criteria on referral selection among general dentists and orthodontists in deciding referrals to oral and maxillofacial surgeons. MATERIALS AND METHODS A cross-sectional study was designed to examine the importance of criteria used by 2 groups of practitioners, general dentists and orthodontists, for deciding on referrals to oral and maxillofacial surgeons. Data were collected by 2 multiple-choice surveys. The surveys were e-mailed to general dentists and orthodontists practicing in the state of Illinois and to graduates from the University of Illinois at Chicago (UIC) College of Dentistry and the UIC Department of Orthodontics. Participants were asked to rate referral criteria from most important to least important. Analysis of variance was used to examine the data for any differences in the importance of the criteria for each question and linear regression analysis was used to determine whether any 1 criterion was statistically meaningful within each group of practitioners. RESULTS In total, 235 general dental practitioners and 357 orthodontists completed the survey, with a 100% completion rate. The most important criterion for referral to oral and maxillofacial surgeons in the general dentist group was the personal and professional relationship of the referring doctor to the specialist. In the orthodontist group, no single criterion was statistically meaningful. CONCLUSION General dentists tend to develop long-term relationships with their patients, and when deciding the appropriate referrals it appears that personal and professional relationships that promote trust and open communication are key elements. General dentists favor these relationships when making referral decisions across a wide spectrum of procedures. Orthodontists do not place a substantial value on a specific criterion for referral and therefore may not develop the same relationships between patient and doctor and between doctors as general dentists.

Complications of Trigeminal Nerve Repair

Injuries to the terminal branches of the trigeminal nerve often heal spontaneously without medical or surgical intervention. In those patients that require treatment, there are a number of complications that may arise from care of these nerve injuries. These adverse sequelae may be at the site of nerve injury, at the nerve graft donor site, or related to the side effects of medications used for neuropathic pain or dysesthesia. In addition, the failure to achieve patient expectations of outcome, or surgeon expectations of success, is also a potentially avoidable but unfortunately a common complication. This chapter will attempt to address adverse outcomes of trigeminal nerve treatment including surgical site complications, donor site complications, and complications of medical management including systemic medications, local injections, or neuroablative techniques.

Anatomic Considerations of the Lips

The lips are a prominent facial feature and play an important role in communication, both verbal and nonverbal, mastication, deglutition, and providing an oral seal. The American Joint Committee on Cancer defines the lip as the junction of the vermillion border with the skin and includes only the vermillion surface or that portion of the lip that comes into contact with the opposing lip. It is well defined into an upper and lower lip joined at the commissure of the mouth. A thorough understanding of lip anatomy allows the surgeon to confidently perform lip reconstruction following tumor resection, understand the basis for selected neck dissections in lip cancer, and provide a high level of patient care. The anatomy of the lip can be broken down into the surface anatomy, microanatomy, and lymphatic anatomy. The aim of this chapter is to provide a comprehensive review of the anatomy of the lip.

Complications from Surgical Treatment of Oral Cancer

Cancer of the oral cavity and oropharynx remains among the top ten most common malignancies in the United States, Europe, and worldwide (Shah et al., Oral cancer, Martin Dunitz an imprint of Taylor and Francis Group, London, 2003). Over the last 30 years the philosophies of treatment of oral cancer have changed very little with regards to primary tumor extirpation, with the exception of marginal mandibular resection. There have been major changes in the approach to cervical lymph nodes at risk for metastasis (Kim and Ord, Oral Maxillofac Surg Clin North Am 15:213–227, 2003). The radical neck dissection, once advocated by Dr. Crile as the only appropriate treatment for the neck, is now rarely performed in most centers (Shah, Cancer of the head and neck – atlas of clinical oncology. In: Management of cervical metastasis. BC Decker Inc, London, 2001). In addition, “organ preservation” protocols involving chemo-radiation therapy, although not without adverse effects, have significantly altered the quality of life for the cancer patient. Also, the ability to offer a variety of reconstruction options with the available hardware, local and regional flaps, as well as free tissue transfer from distant sites, has contributed to the overall significant improvements in functional and esthetic outcomes. The head and neck cancer patient in the new millennium has the opportunity to emerge from an extensive ablative surgical procedure with excellent functional and esthetic results. Despite these surgical advances, the ablative process still results in the sacrifice of several functional and esthetic organs during surgery for cancer of the oral cavity (Shah, Cancer of the head and neck – atlas of clinical oncology. In: Management of cervical metastasis. BC Decker Inc, London, 2001). Early complications from ablative surgery for oral cancer are, for the most part, similar to those from other sites. Long term complications however are quite challenging for the oncologic team as well as the patient who survives oral cancer, primarily due to the highly specialized regional tissues involved in the surgical field.