Oral and Maxillofacial Surgery

Primary Oral Presentation of Sarcoidosis in a Pediatric Patient Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Chad Dammling, Peter Waite, Timothy Beukelman Sarcoidosis is a multisystem granulomatous disease of unknown etiology that commonly affects the lungs, lymph nodes, and skin. The disease often presents in patients between the third and sixth decade and its pathology is defined by the presence of noncaseating granulomas within organs throughout the body. Oral and neurologic involvement of sarcoid is extremely rare and occurs in approximately 1% and 5% of patients with the disease, respectively. A case of sarcoidosis involving the gingiva and submandibular lymph nodes is described in a 14-year-old girl. Further neural involvement of the disease was recognized after initial biopsy examinations and systemic evaluation. This presentation is especially rare given the patient's lack of symptoms, age at diagnosis, and initial oral manifestations.

News and Announcements Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s):

The Inverted Coronoid-Ramus Graft for Condylar Reconstruction Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Leslie B. Heffez The purpose of this article is to describe a creative, versatile technique for condylar reconstruction using autogenous mandibular bone. The technique has been used for reconstruction of small condyle and/or ramus defects (approximately 35 to 40 mm in length) typically associated with condylar hyperplasia, condylar tumors, idiopathic condylar resorption, and failed reconstruction attempts. The technique involves excision of the ipsilateral coronoid process–mandibular ramus, inverting it and rotating the segment 180° along its horizontal axis to replace the excised condyle. The resultant graft simulates the morphology of the posterior aspects of the ramus and condyle and has been shown to resist resorption typical of endochondral bone grafts harvested from the rib or iliac crest. Grafting is carried out via vestibular and preauricular or endaural incisions. Four cases followed over a period of 3 to 40 months (average, 21 months) are presented. No adverse functional results, including ankylosis, removal of hardware or adverse remodeling, have occurred. A period of intermaxillary fixation is used because it is considered beneficial for intra-articular scarring of the subglenoid fossa pad (disc or retrodiscal tissue and fibrocartilage) and initial healing. Physical therapy has not been prescribed. The inverted coronoid graft is a versatile technique when virtual surgical planning is used to assess feasibility, as well as defect and graft dimensions; fabricate custom bone plate and drilling guides; and determine screw osteosynthesis sites. In general terms, a post-reconstruction opening of 35 mm allows for adequate function and guards from contralateral symptomatic hypermobility given disparate right- and left-sided joint mechanics. In the cases described, a mean of 40.5 mm was achieved; however, in 2 of these cases, this was measured with undesirable asymptomatic (preoperative) deviation to the ipsilateral side by greater than 4 mm and by 6 mm. The inverted coronoid graft technique reduces operative time, can be executed with few external scars, and reduces the number of operative fields.

Reconstruction of the Oral Commissure With the Zisser Flap Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Konstantinos Mantsopoulos, Heinrich Iro, Jannis Constantinidis The aim of this study was to investigate the role of the Zisser flap in the reconstruction of defects of the oral commissure. We describe our personal experience with this method and present some interesting aspects from the relevant literature. We retrospectively evaluated the records, from the period between 2003 and 2017, of all patients with defects of the oral commissure after resection of malignant tumors, traumas, or burns and reconstruction by means of the Zisser flap. We looked for information on the origin of the commissural defect, method of vermillion reconstruction using the lingual or buccal mucosa, functional result, esthetic outcome, and postoperative complications. The functional result of the reconstruction of the oral commissure was assessed regarding postoperative subjective speech integrity, preservation of competence of the oral sphincter, and lip sensation. The esthetic outcome was evaluated regarding limitations in facial expression and scar formation. The study included 13 patients. The follow-up period in the oncologic cases was 63.2 months (range, 10 to 140 months). No tumor recurrences were detected. Vermillion reconstruction was achieved by means of a buccal mucosal flap in 11 cases and a lingual mucosal flap in 2. All patients achieved normal oral competence and mouth opening except for 1 case, in which secondary commissuroplasty with restoration of sphincter function was needed. No cases of blunting or microstomia were detected. Reconstruction of the oral commissure with the Zisser flap is associated with an outstanding functional outcome that is cosmetically very acceptable.

Use of a 3-Dimensional Custom-Made Porous Titanium Prosthesis for Mandibular Body Reconstruction With Prosthetic Dental Rehabilitation and Lipofilling Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Gaoussou Touré, Emmanuel Gouet Reconstruction of mandibular substance loss by a free flap is a widely used technique. This technique suffers from several disadvantages, including the presence of a second intervention site and a substantial frequency of complications. We have undertaken a custom-made 3-dimensional reconstruction (using computer-aided design and manufacturing) with prosthetic dental rehabilitation and esthetic improvement by lipomodeling of the face. A 50-year-old woman presented with a massive recurrence of an ameloblastoma of the right hemimandible. A cervical approach was used to resect the mandible well away from the tumor site. In light of her refusal to undergo reconstruction by a fibula free flap, reconstruction was performed using a custom-made porous titanium device with dental prosthetic rehabilitation, followed by lipomodeling of the face. The reconstruction was achieved without the occurrence of any complications. The implant-supported prosthetic dental implantation and the lipofilling resulted in functionally and esthetically satisfactory outcomes. Three-dimensional mandibular reconstruction with a custom-made porous titanium device and lipofilling yielded satisfactory results. Fitting of the dental prosthesis was undertaken at an early stage as it did not require osseointegration, although there was a need to overcome difficulties linked with the seal and the stability of the dental prosthesis and titanium support. The duration of patient follow-up was 18 months.

Functional Reconstruction of Mandibular Segment Defects With Individual Preformed Reconstruction Plate and Computed Tomographic Angiography-Aided Iliac Crest Flap Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Maorui Zhang, Pengcheng Rao, Delin Xia, Libo Sun, Xiaoxiao Cai, Jingang Xiao Purpose With the development of imaging technology and computer-assisted surgery in oral and maxillofacial surgery, digital technology is widely used in vascularized bone flap grafts for mandibular reconstruction. The aim of this study was to use digital technology throughout the treatment process to show that digital techniques can provide a reliable and accurate match between the mandible and the iliac crest flap to achieve functional reconstruction of mandibular segment defects. Materials and Methods Twenty patients underwent 3-dimensional (3D) computed tomography (CT), mirroring technology, 3D model prototyping, and CT angiography (CTA) for treatment planning. Individual preformed reconstruction plates were fabricated and iliac crest flaps were designed preoperatively. After complete resection of the mandibular lesion, the iliac crest flap was shaped to reconstruct the mandibular defects. Results During follow-up (range, 12 to 36 months), the facial shape, facial symmetry, and mouth opening of all patients recovered well. The 3D CT reconstruction also was evaluated for height, width, length, and bone healing of the iliac crest flap. Postoperative examination showed ideal bone union between the iliac crest flap and the mandible at 6 months. Nine patients received implant-supported fixed dentures to restore dentition. After follow-up, all patients were satisfied with their facial esthetics and function. The new mandible provided a suitable 3D position for implant-supported fixed partial dentures. Conclusion Use of digital techniques throughout the course of treatment improves the predictability and convenience of functional mandibular reconstruction. Individual preformed reconstruction plates and CTA effectively guaranteed the accuracy of iliac flap preparation.

Changes in Condylar Position After Mandibular Reconstruction With Condylar Head Preservation by Computed Tomography Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Wei Wang, Xiao-feng Shan, Jie Liang, Shang Xie, Jie Zhang, Zhi-gang Cai Purpose Condylar position can change after mandibular reconstruction using the free fibula flap. The present study evaluated changes in condylar position using computed tomography (CT) after mandibular reconstruction with condylar head preservation. Materials and Methods This retrospective study consisted of 16 patients. CT data of 32 temporomandibular joints (TMJs) were recorded before surgery (T0), 7 to 10 days after surgery (T1), and 16.8 ± 7.4 months after surgery (T2). The anteroposterior condylar position was evaluated using the method of Pullinger and Hollender (Oral Surg Oral Med Oral Pathol 62:719, 1986). Repeated-measures analysis of variance (P = .05) was performed. Results Data of 16 patients were obtained for statistical analysis. Condylar position changed over time after mandibular reconstruction. The ipsilateral condyles moved anteroinferiorly after surgery (T0 to T1) and tended to move anterosuperiorly during follow-up (T1 to T2). No major changes were noted in the contralateral condyles. Conclusion Condylar positions showed obvious changes over time after mandibular reconstruction with condylar preservation. Nevertheless, additional studies are warranted to further evaluate the relation between condylar position and TMJ function.

The Inferior Alveolar Nerve: To Graft or Not to Graft in Ablative Mandibular Resection? Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Maryam Akbari, Michael Miloro Purpose To determine contemporary surgical decision-making processes regarding the use of a nerve graft with ablative mandibular resection and to identify utilization barriers among head and neck surgeons. Materials and Methods An online electronic survey that queried practice patterns and subjective opinions regarding inferior alveolar nerve (IAN) grafting at the time of mandibular resection was distributed to head and neck surgeons and oral and maxillofacial surgery residency program directors (N = 249) by use of REDCap. Results The response rate was 37%. Only 10.6% of respondents perform IAN reconstruction “always” (60% “usually” or “sometimes” and 28.8% “rarely” or “never”) with ablative benign mandibular resection, whereas only 1.1% perform IAN grafting always (10-20% usually or sometimes and 89% rarely or never) with ablative malignant mandibular resection. Among the 93 participants, the most important utilization barriers were lack of evidence for improving quality of life, potential impact of radiation on nerve healing, and lack of efficacy for restoration of neurosensory function. Conclusions Despite evidence-based literature showing the efficacy of immediate IAN grafting with ablative benign mandibular resection, most head and neck surgeons do not perform this procedure routinely in patients with benign or malignant mandibular pathology. Future research should focus not only on the achievement of functional sensory recovery but also on the impact of IAN grafting on improved quality-of-life indicators in both benign and malignant mandibular disease, with and without adjunctive chemoradiation therapy.

Is Single-Photon Emission Computed Tomography/Computed Tomography Superior to Single-Photon Emission Computed Tomography in Assessing Unilateral Condylar Hyperplasia? Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Pingan Liu, Jun Shi Purpose Single-photon emission computed tomography (SPECT) with technetium-99m diphosphates plays an important role in assessing unilateral condylar hyperplasia (UCH). The aim of this study was to evaluate whether quantification methods of SPECT plus CT (SPECT/CT) based on precise region-of-interest (ROI) drawings made under the guide of CT images were more accurate than conventional SPECT methods in the assessment of UCH growth. Materials and Methods This study is a nonblinded retrospective case series. Patients with UCH who had undergone SPECT/CT were enrolled. CT images were used to guide ROI drawings around the anatomic contour of the affected and contralateral condyles on SPECT/CT images versus fixed ROIs on conventional SPECT images. Mean and maximum values within the ROIs were recorded to compute percentile ratios. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) curves were calculated separately for SPECT-based methods (SPECTaver, SPECTmax) and SPECT/CT methods (SPECTCTaver, SPECTCTmax). The area under the ROC curve of each method was calculated and compared pairwise. Results Fifty-six patients (30 patients with progressive and 26 patients with nonprogressive mandibular asymmetry) were evaluated. SPECTmax had the highest sensitivity of 83.3%, followed by SPECTCTmax, SPECTaver, and SPECTCTaver. In contrast, SPECTaver, SPECTCTmax, and SPECTmax had similar specificities, PPVs, and NPVs. Nonetheless, SPECTCTaver had the lowest specificity, PPV, and NPV among all methods. ROC analysis also showed similar diagnostic performances among SPECTaver, SPECTmax, and SPECTCTmax (P > .05) and poorer diagnostic performance of SPECTCTaver compared with the other 3 methods (P < .05). Conclusions The method of using ROIs drawn around the contour of the condyle on SPECT/CT images does not show improved accuracy over conventional SPECT-fixed ROI methods in assessing UCH.

A Paradigm Shift in the Management of Cherubism? A Preliminary Report Using Imatinib Publication date: June 2019 Source: Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 6 Author(s): Pat Ricalde, Imran Ahson, Samantha T. Schaefer Cherubism is an autosomal-dominant inherited mutation in the SH3BP2 gene on chromosome 4p16.3. It is characterized by bilateral symmetric fibro-osseous lesions that are limited to the maxilla and mandible. The lesions present in early childhood and typically spontaneously involute after puberty. Current standard practice is to reserve surgery for symptomatic or severely disfiguring cases. This report presents 3 patients with cherubism who exhibited marked reduction in tumor size with imatinib, a tyrosine kinase inhibitor. Treatment was well tolerated, with few side effects.