Vincent B. Ziccardi

Management of the oral and maxillofacial surgery patient with end-stage renal disease

Chronic renal failure (CRF) is the consequence of a multitude of diseases that cause permanent destruction of the nephron. Concurrent with renal failure are a host of changes affecting the homeostatic functioning of the individual. This report outlines the pathophysiology of CRF and highlights its effects on surgical manipulation of the oral and maxillofacial region in this patient population. In addition, some of the common physical findings and alterations in blood chemistries frequently observed in these patients are discussed.

Lateral canthotomy transconjunctival approach to the orbit

Multiple surgical approaches to the orbits with the use of the eyelids have been used. The orbital rim incision fell into disfavor because of esthetic considerations. A subciliary approach supplemented by the lateral brow incision is currently the most popular method of approach to the orbital rim. It provides adequate access to the orbit, but it is not without inherent complications, such as unfavorable scarring, ectropion, and entropion. This article describes an alternate approach to the orbit by means of a transconjunctival incision with lateral canthotomy.

Maxillofacial considerations in orthotopic liver transplantation

Orthotopic liver transplantation is now a widely used treatment for patients with end-stage liver disease. Lifelong pharmacologic immunosuppression renders these patients susceptible to many infections. The purpose of this article is to provide guidelines for treating the patient with end-stage liver disease, both before and after transplantation. In addition, we shall discuss some of the medical implications associated with end-stage liver disease and their clinical presentations and appropriate presurgical management. Adverse side effects of long-term immunosuppression and their effect on the oral and maxillofacial region shall also be discussed. Last, a brief discussion of FK506, the latest immunosuppressant, will be presented together with the implications of its use on our surgical treatment of these patients.

Management of a severe zygomatico-orbital fracture with dislocation of the globe into the antrum.

A patient with severe orbital facial trauma with complete dislocation of the globe into the maxillary antrum is presented. Reconstruction of the defect with autogenous bone restored globe position and maintained the visual and ocular-rotary function of the eye.

Innervation pattern of the temporalis muscle.

The purpose of this article is to describe the neural anatomy of the temporalis muscle as dissected along the intramuscular temporal fascial plane. This sagittal plane is a natural cleavage plane of the muscle, which is explored along with its relationship to the deep temporal nerve. Eight temporalis muscle specimens were removed in their entirety from 8 preserved cadavers. The muscles were selected based on whether they were grossly intact prior to procurement for processing. The muscle specimens were then processed over a 3-month period using Sihlers staining technique. Muscle dissection was performed along the intramuscular fascial plane under an operating microscope, taking care to preserve the underlying nerve and arterial anatomy. Dissections demonstrated an anterior and posterior division of the deep temporal nerve running within the deep portion of the muscle below the intramuscular fascial plane. This fascial layer provided a natural dissection plane to expose and evaluate the underlying nerve and arterial anatomy. In all specimens the deep temporal artery originated with the anterior temporal nerve and then branched into an anterior and posterior division. The innervation density and nerve caliber of the anterior portion of the muscle was much greater than that of the posterior, correlating with a greater anterior muscle bulk. This may have implications in differences in fiber type and functional regionalization of the muscle. The results of this anatomic study support the finding of an anterior and posterior division of the deep temporal nerve within the deep portion of the temporalis muscle. In addition, differences in the innervation density and muscle bulk lend credence to the possibility of regional muscle specialization. The natural cleavage plane of the intramuscular temporal fascia may have clinical ramifications for temporalis myofascial flaps while preserving the underlying neural anatomy to allow for normal residual temporalis muscle function.

Peripheral trigeminal nerve surgery for patients with atypical facial pain.

Atypical facial pain (AFP) is characterized by a constant, poorly defined anatomically aching pain, lacking the paroxysmal quality, trigger point activation, and well-defined anatomical distribution of trigeminal neuralgia. This study examines a set of AFP patients with respect to their responses to external decompression (4 patients) and neurectomy (11 patients). Criteria for trigeminal nerve exploration were: failure of non-operative treatments, the ability to control pain temporarily with local anesthetic nerve blocks, and pain generally located within the anatomical distribution of the affected nerve. Decision as whether to perform an external decompression or neurectomy was based on gross anatomical findings during exploration. A retrospective interview was conducted to evaluate the effects of the chosen procedure in regard to subjective level of pain, freedom from restrictions placed on activities of daily living, and past medical history, including history of the facial pain. The neurectomy procedure (p = 0.022), medical history of autoimmune disease (p = 0.004), and preoperative pain distribution on the left side (p = 0.042), were all found to have a positive effect on outcome. History of psychiatric treatment (p = 0.055) and preoperative affected activities of daily living (p = 0.026) significantly adversely affected the outcome.

Indications for enteric tube feedings in oral and maxillofacial surgery

The catabolic effects of surgical trauma and sepsis have long been recognized. Oral and maxillofacial surgical patients represent a unique group in that their surgery and its effects on the stomatognathic system may adversely affect the ability to receive adequate nutrition. This article discusses some basic nutritional principles and describes the indications and guidelines for enteric tube feeding in this patient population.

Intramuscular temporalis fascia: a guide to procurement of temporalis myofascial flaps.

The purpose of this study is to demonstrate an intramuscular fascial layer within the temporalis muscle. This can be used as an inferior plane when developing a temporalis myofascial flap for temporomandibular joint reconstruction. The advantages of using this plane include relatively bloodless zone, adequate thickness of flap for reconstructive purposes, and residual temporalis muscle to prevent the temporal concavity deformity. Cadaveric and clinical examples are presented.

Technical innovation: transfacial approach for infraorbital nerve exploration and orbital-maxillary surgery.

Abstract A transfacial approach for infraorbital nerve exploration and maxillary surgery has been developed, allowing for good visual access as far posteriorly as the foramen rotundum and anterior maxillary region. This allows for infraorbital osteotomies, peripheral nerve grafting, neurolysis procedures, or combined maxillofacial-neurosurgical procedures with gasserian ganglion exploration and/or grafting. The procedure affords maximum surgical accessibility with good postoperative healing and minimal concerns about potential oral contamination.

Nuclear dacryoscintigraphy : its role in oral and maxillofacial surgery

Obstruction of the lacrimal drainage apparatus may result in excessive tearing or epiphora. This may occur as a result of a traumatic injury or accumulation of debris, mucus, or pus. In nuclear dacryoscintigraphy, a radioactive solution is introduced into the conjunctival sac by pipette and allowed to follow the flow of the tear solution through the lacrimal drainage system. This article will review normal lacrimal anatomy and indications for nuclear dacryoscintigraphy in oral and maxillofacial surgery.