Comment on “Investigation of an Opioid Prescribing Protocol After Third Molar Extraction Procedures”
Substantial change to deeply ingrained and long-standing habits is never easy; individuals in the behemoth of a major university dental school are especially hard to budge. Tompach et al1 should be commended for a common-sense and evidence-based approach that has accomplished not just a token reduction in opioid prescribing but a seismic shift in the culture of managing acute pain at the University of Minnesota School of Dentistry in a remarkably short time.
Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Published online: April 20, 2019
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Hypercementosis and Cementoblastoma: Importance of the Histopathologic Analysis for the Correct Diagnosis
Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Published online: April 18, 2019
We have read with great interest the recently published article by Borges et al,1 “Conservative Treatment of a Periapical Cementoblastoma: A Case Report,” describing a 33-year-old woman who underwent a conservative approach (endodontic treatment). After 7 years of follow-up, no recurrence was detected and the tooth maintained its masticatory function. It is noteworthy that this case shows excellent documentation of the clinical, imaging, and surgical procedures; however, we believe that, considering the common location of the cementoblastoma, the description “cementoblastoma” or “benign cementoblastoma” instead of “periapical cementoblastoma” is more appropriate.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
A Foundational Framework for Andragogy in Oral and Maxillofacial Surgery III. Emotional Intelligence
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: January 26, 2019; Accepted: February 4, 2019;
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Wireless Monitoring for Office-Based Anesthesia
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: January 10, 2019; Accepted: January 11, 2019; Published online: January 29, 2019
Current research on wireless hemodynamic monitoring during anesthesia is limited as the topic is just beginning to be explored. The aim of this article is to stimulate technological advancements in monitored anesthesia care that will increase safety and efficiency. Here, we introduce this exciting new concept and propose an innovative model for monitoring patients undergoing office-based anesthesia.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Musculoskeletal Disorders in Oral and Maxillofacial Surgeons: A Resident’s Perspective
Vickas Agarwal, DDS∗,
Correspondence information about the author DDS Vickas Agarwal
Email the author DDS Vickas Agarwal
Correspondence information about the author DDS Vickas AgarwalEmail the author DDS Vickas Agarwal
Resident, Division of Oral and Maxillofacial Surgery, Parkland Memorial Hospital/UT Southwestern Medical Center, Dallas, TX
Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: January 25, 2019; Accepted: January 27, 2019; Published online: February 12, 2019
Musculoskeletal disorders (MSDs) are a common issue among health care providers and especially among dentists and surgeons. Dentists are most likely to be affected by MSDs, followed by surgeons.1 Current literature addressing MSDs in oral and maxillofacial surgeons (OMSs) is limited, but what data there are create cause for concern. According to Ratzon et al,2 OMSs were almost twice as likely as general dentists to have musculoskeletal pain. Furthermore, OMSs had the highest human workload score, likely attributed to reduced movement (despite dental assistance being more common in our specialty) and longer periods without breaks.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Do Oral and Maxillofacial Surgeons Over-Prescribe Opioids After Extraction of Asymptomatic Third Molars?
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: December 13, 2018; Accepted: February 6, 2019; Published online: February 16, 2019
Purpose
Opioid abuse is a public health concern. Oral opioids are prescribed after removal of third molars, but the amount needed for adequate postoperative analgesia is unknown. The purpose of this study was to quantify opioid need after third molar extractions.
Materials and Methods
This is a prospective cohort study of consecutive patients who had asymptomatic third molars extracted with intravenous sedation at the Boston Children's Hospital (Boston, MA) from June through October 2018 by 3 attending surgeons. To be included, patients had to have had 4 third molars removed. Patients were excluded if they had a concomitant procedure, preoperative infection, postoperative inflammatory complication, chronic pain condition, or did not complete the study. Postoperative prescriptions and instructions included 1) oxycodone 5-mg tablets with 1 tablet taken every 6 hours as needed (dispensed, 6); 2) ibuprofen 600-mg tablets with 1 tablet taken every 6 hours as needed (dispensed, 20); and 3) acetaminophen 325-mg tablets with 2 tablets taken every 6 hours as needed (dispensed, 40). Participants reported medication use by electronic questionnaire each day for 7 postoperative days (PODs). Descriptive statistics were calculated.
Results
Eighty-one patients (56% female; mean age, 19.4 ± 7.7 yr) were included. The average number of oxycodone tablets used was 0.04 ± 0.24, and the highest daily use of oxycodone was on POD 2 (1.0 ± 0.0 tablet). Oxycodone was taken by 3 patients (4%) on POD 1, 4 (5%) on POD 2, 2 (3%) on PODs 3 and 4, and 0 on PODs 5 to 7. Seventy-five patients (93%) used no postoperative oxycodone; 466 prescribed oxycodone tablets remained unfilled or unused. Ibuprofen 600 mg was used for 4.6 ± 2.2 PODs and acetaminophen 650 mg was used for 3.4 ± 1.9 PODs.
Conclusions
Oral opioid use after third molar extractions is minimal. Caution is necessary to avoid over-prescribing.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Relationship Between Surgical Difficulty of Third Molar Extraction Under Local Anesthesia and the Postoperative Evolution of Clinical and Blood Parameters
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 12, 2018; Accepted: February 12, 2019; Published online: February 19, 2019
Purpose
To determine whether the Pederson scale is a good predictor of the surgical difficulty of third molar extraction and establish whether such surgical difficulty is directly related to the postoperative course as assessed from clinical (pain, inflammation, and trismus) and blood (C-reactive protein, interleukin-6 [IL-6], and fibrinogen) parameters.
Materials and Methods
A prospective observational study was conducted of 2 groups of patients who underwent simple or surgical third molar extraction under local anesthesia. Clinical and blood parameters and possible complications were recorded for 1 week after extraction.
Results
A total of 118 patients were studied. Surgical difficulty as predicted by the Pederson scale showed significant differences (P < .001) for osteotomy, sectioning of the crown, root sectioning, duration of intervention, type of closure, and number of sutures. Under conditions of equal surgical difficulty, the evolution of the groups was similar for pain and inflammation, although trismus was greater for patients subjected to surgical extraction. After the operation, marked increments were recorded in serum C-reactive protein, IL-6, and fibrinogen, although without differences among different levels of surgical difficulty. The probability of complications was similar in the routine and surgical extraction groups. The appearance of complications was the principal cause of alterations in clinical and blood parameters.
Conclusions
The Pederson scale is a good predictor of the surgical difficulty of third molar removal as assessed from different clinical and blood parameters. C-reactive protein, IL-6, and fibrinogen concentrations varied considerably after the operation but were not influenced by the degree of surgical difficulty. The presence of postoperative complications was associated with a poorer evolution of clinical and blood parameters.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Is Noise From Suctioning Harmful to Surgeons' Hearing?
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 10, 2018; Accepted: February 6, 2019; Published online: February 25, 2019
Purpose
A growing concern in the community of oral and maxillofacial surgeons (OMSs) is the progressive hearing loss that has become more evident in older surgeons. Very few studies have focused on the effects on a surgeon's hearing based on his or her environment. The purpose of this study was to investigate whether the noise produced by suction, compared with federal guidelines, could have a damaging effect on the hearing of OMSs.
Materials and Methods
A CEM DT-8851 industrial high-accuracy digital sound noise level meter data logger (CEM Instruments, Bengal, India) was used to capture the sound intensities in various procedures. The sound meter was used to record the intensities of sound produced, in decibels, in clinics and operating rooms. The analysis was divided into different variables: non-drilling/suction (in which neither a drill nor suction was used but suction was on), suction, drilling, suction and drilling, suction and irrigation, and Yankauer suction.
Results
A total of 50 clinic and 50 operating room procedures were recorded, focusing on suction. The noise intensities captured were analyzed based on federal workplace standards. Compared with non-drilling/suction, all other noise exposures on average were greater in intensity and statistically significant with P < .0001. Both the maximum and minimum intensity recorded occurred during non-drilling/suction periods. Noise intensities exceeded 85 dB only 0.04% of the time.
Conclusions
The hypothesis that suction noise intensity would exceed federal guidelines was not supported and therefore was not accepted. However, it cannot conclusively be said that surgeons are not experiencing hearing loss due to their work-related noise exposure. The extent to which OMSs are exposed to this type of setting could be the cause of their progressive hearing loss because federal guidelines are based on 8-hour workdays and 16 hours of being in a quiet environment. A longitudinal study observing specific surgeons through a substantial period would perhaps be able to give more definitive results.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Root Elongation After Autotransplantation in 58 Transplanted Premolars: The Radiographic Width of the Apex as a Predictor
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 14, 2018; Accepted: February 11, 2019; Published online: February 19, 2019
Purpose
Autotransplantation of premolars with incomplete root development is a reliable treatment option for tooth replacement. Nevertheless, little is known about root development after transplantation of teeth. The aim of this study was to evaluate preoperative root development stage and radiographic width of the apex as predictors for root elongation after autotransplantation.
Materials and Methods
A retrospective cohort study was implemented and composed of patients who underwent autotransplantation of at least 1 premolar. Using panoramic radiographs (orthopantomograms), calibrated measurements were taken to record the root development stage of the donor tooth, width of the apex, and root length of the transplanted tooth.
Results
Forty-five patients (58 transplants) were included. Mean follow-up time was 12 months (range, 4 to 26 months). Fifty-three transplanted teeth (91.4%) showed root elongation. Mean root elongation at end of follow-up was 1.9 mm (range, 0.0 to 4.3 mm). A wide-open apex before transplantation was significantly associated with root elongation after autotransplantation (P < .01). Root development stage (P = .82) did not show significant associations with root elongation.
Conclusions
A wide-open apex (>2.0 mm) is an important predictor of root elongation after autotransplantation of premolars. This might be a better predictor for root development than preoperative root development stage.
© 2019 Published by Elsevier Inc.
Development of a New Index to Assess the Difficulty Level of Surgical Removal of Impacted Mandibular Third Molars in an Asian Population
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: October 25, 2018; Accepted: March 6, 2019; Published online: March 13, 2019
Purpose
This study aimed to develop a straightforward and accurate index of impacted third molar removal difficulty through analyzing various factors to assess the difficulty level of impacted mandibular third molar (IMTM) extraction.
Materials and Methods
This prospective cohort study included 203 patients who required IMTM extraction. All patients were selected using the preset selection criteria. The present study assessed operation difficulty with operating time. A mathematical model and regression analysis were performed to explore 6 main factors (age, number of roots, degree of bone impaction, shape of roots, and impaction angle and its relation). Appropriate correction coefficients were obtained to formulate a new IMTM removal difficulty predictive index. Consistency of the κ value was checked to evaluate performance.
Results
Degree of bone impaction had the highest correlation coefficient (0.576), followed by shape of roots (0.359), and the lowest correlation coefficient was for number of roots. The Pederson index for these 203 patients showed that 75, 76, and 52 patients had low, moderate, and high difficulty levels, respectively, whereas the new index categorized 78, 85, and 40 patients as having low, moderate, and high difficulty. Comparison of the Pederson index and new index with operating time showed κ agreements of 65.30 and 77.9% (P < .01), suggesting that the prediction results of the new index are more objective and accurate.
Conclusion
The newly proposed index is straightforward and efficient and exhibited promising results in κ agreement. Because of its straightforward nature, it is better suited for Chinese public hospitals with a large volume of patients who require alveolar surgery. The detection of predictor variables could be useful for graduate students, professionals, and general dental practitioners contemplating IMTM removal to assess the difficulty level of IMTM extraction.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Is Repeated Arthrocentesis Beneficial in the Treatment of Temporomandibular Disorders: A Retrospective Study
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: October 10, 2018; Accepted: January 24, 2019; Published online: February 05, 2019
Purpose
Arthrocentesis is an effective, simple, and minimally invasive treatment in patients with temporomandibular joint (TMJ) closed lock (CL). The aim of this study was to compare the effectiveness of 1- versus 2-session arthrocentesis procedures in the management of TMJ CL.
Materials and Methods
A retrospective cohort study was conducted using the files of patients with TMJ CL according to diagnostic criteria for temporomandibular disorders. Patients who underwent 1- or 2-session arthrocentesis were included in the study. The decision of whether to undergo 1- or 2-session arthrocentesis was made by the patients: Those who accepted a second arthrocentesis procedure were assigned to group 1 (repeated arthrocentesis group), and those who did not accept, to group 2 (arthrocentesis group). The primary predictor variable was treatment method. TMJ pain (scored on a visual analog scale) and maximum mouth opening (MMO) were selected as the outcome variables. To evaluate the clinical outcomes of 1- or 2-session arthrocentesis, MMO and pain score (on a visual analog scale) before treatment and at 1, 3, and 6 months' follow-up were analyzed. Descriptive, comparative, correlation, and multivariate analyses were conducted.
Results
A total of 30 patients (25 female and 5 male patients) with TMJ disc displacement without reduction were enrolled in the study. Each group consisted of 15 patients. Statistically significant decreases in pain scores and increases in MMO values were observed in both treatment groups at 3 and 6 months (P < .05). At 6 months, MMO values were significantly higher and pain levels were significantly lower in patients who received 2 arthrocentesis procedures.
Conclusions
Repeated arthrocentesis is more successful at reducing pain and improving MMO than a single intervention in the treatment of TMJ CL.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Comparison of Intra-Socket Bupivacaine Administration Versus Oral Mefenamic Acid Capsule for Postoperative Pain Management Following Removal of Impacted Mandibular Third Molars
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: June 7, 2018; Accepted: January 18, 2019; Published online: January 25, 2019
Purpose
Surgical removal of impacted third molar teeth is one of the most common surgical procedures performed in oral and maxillofacial surgery. Postoperative pain is a common and predictable occurrence after maxillofacial surgery.
Materials and Methods
This randomized double-blind clinical trial was conducted with a crossover design in which each patient served as his or her own control. Forty-six patients with similar bilateral impacted lower third molars were selected. In each patient, the intervention and control sides of the mandible were randomly determined at the end of surgery. If the removed tooth was in the intervention side, then the patient would receive bupivacaine and a placebo of mefenamic acid. If the impacted tooth was in the control side, then the patient would receive a mefenamic acid capsule and a placebo of bupivacaine. Pain severity was assessed using a visual analog scale. Data were analyzed using paired-sample t test and a P value less than .05 was considered statistically significant.
Results
Of 46 participants originally recruited, 43 were included in the present study. The mean postoperative pain score in patients who received bupivacaine was increased to a maximum 4 hours, with marked improvements after this time. The mean intensity of pain after administration of bupivacaine was lower than that of mefenamic acid capsules at different time points. Statistical analysis showed a relevant difference in pain intensity between the 2 study groups.
Conclusion
The results of the present study showed that local administration of bupivacaine relieves postoperative pain after surgical removal of impacted third molar teeth.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Material Hypersensitivity and Alloplastic Temporomandibular Joint Replacement
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: December 10, 2018; Accepted: January 26, 2019; Published online: February 06, 2019
Purpose
There appears to be little consensus on how to evaluate and manage patients reporting a possible allergic reaction to joint replacement devices containing metal. This article presents an analysis of the current orthopedic literature in this regard as it relates to diagnosis, testing, and management. Based on that evidence, a management algorithm for metal hypersensitivity in the patient receiving an alloplastic temporomandibular joint replacement is proposed.
Materials and Methods
Orthopedic surgery has recognized metal sensitivity as a problem in joint replacement; using a PubMed search for this topic, the pertinent orthopedic literature was reviewed.
Results
Metal hypersensitivity response to implant materials is often a diagnosis of exclusion. The 2 most commonly used tests are the in vivo skin patch test and in vitro lymphocyte transformation test. Initially, conservative management is indicated and other more common causes of symptomatic total joint replacement should be fully explored. Device removal should be considered a last resort.
Conclusions
Before a primary total joint replacement, testing could be helpful when a patient reports a history of intolerance to jewelry or of an allergic reaction to a prior metal implant. However, to date, routine testing is not supported by the literature.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Trainee Contribution Is Not Associated With Citation Frequency: A Retrospective Study
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: October 28, 2018; Accepted: January 17, 2019; Published online: January 28, 2019
Purpose
Publication citation frequency is a measure of scientific influence. The purpose of this study was to measure the association between trainee involvement in publications and citation frequency.
Materials and Methods
A retrospective cohort study of the Journal of Oral and Maxillofacial Surgery from January to December 2010 was conducted. For each included publication, the study topic and design were recorded. The primary predictor variable was trainee involvement (yes or no). For the purpose of our study, the term “trainee” encompassed dental students, graduate (non-dental) students, oral and maxillofacial surgery residents, and non–oral and maxillofacial surgery residents, as indicated by author affiliations listed in each article. The outcome variable was the number of citations accumulated between 2010 and 2017. Descriptive statistics were computed. Analyses of variance were performed to compare citation distribution among study types and designs. Student t tests and χ2tests were performed.
Results
The sample consisted of 111 publications, of which 85 (76.6%) had at least 1 trainee author. Among all publications, the mean number of citations was significantly different across study designs (P = .03), with case reports earning the lowest number of citations on average (mean, 14.9 citations). Trainee publications had significantly different distributions of study topics (P = .02) and designs (P < .01). Among publications with a trainee author, the most common topic was pathology (37%) and the most common study design was a case report (45%). Despite the higher proportion of case reports, the mean number of citations between trainee (mean, 30.4 citations) and non-trainee (mean, 30.5 citations) publications was not significantly different (P = .99).
Conclusions
Including trainees does not alter the citation frequency of the articles published in the Journal of Oral and Maxillofacial Surgery. This finding is encouraging to both academic surgeons and their trainees, as a higher volume of students and residents can be engaged in research while preserving the influence of the published works.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Tapered Versus Cylindrical Implant: Which Shape Inflicts Less Pain After Dental Implant Surgery? A Clinical Trial
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 14, 2018; Accepted: February 14, 2019; Published online: February 25, 2019
Purpose
Because no study has evaluated the postoperative pain caused by the shape of dental implants, this study compared the level of postoperative pain between tapered and cylindrical implants inserted in the posterior region of the maxilla.
Materials and Methods
The study was designed as a double-blinded randomized clinical trial and conducted in 50 healthy patients 20 to 60 years old who were edentulous in the posterior maxilla and were candidates for single implantation. All patients had the same surgical difficulty with appropriate bone width and height. BioHorizons (Birmingham, AL) implants (tapered vs cylindrical) with 4.5-mm platform diameter were randomly selected for each group. The visual analog scale was used to evaluate the level of pain. Pain severity in each group was measured at 30-minute, 3-hour, 6-hour, 12-hour, 24-hour, 2-day, 3-day, and 1-week intervals. The predictor variable was implant shape and the outcome was postoperative pain severity. Data were statistically analyzed with SPPS 16 (SPSS, Inc, Chicago, IL) at the significance level of a P value less than .05.
Results
Fifty patients (n = 25 per group) with the mean age of 43.7 ± 10.9 years were included in this study. The pain level in the 2 groups reached its maximum at the 6-hour postoperative interval. Pain severity decreased significantly over time in the 2 implant groups (P < .001). Severities of postoperative pain in the tapered group at 3-, 6-, 12-, and 24-hour intervals were statistically lower than those in the cylindrical group (P < .05).
Conclusions
Implant shape had an impact on postoperative pain. It can be concluded that tapered implants lead to less postoperative pain compared with cylindrical ones.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
What is the Prevalence of Undiagnosed Nevoid Basal Cell Carcinoma Syndrome in Children With an Odontogenic Keratocyst?
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: January 8, 2019; Accepted: January 22, 2019; Published online: February 05, 2019
Purpose
Odontogenic keratocysts (OKCs) can occur in isolation or as part of nevoid basal cell carcinoma syndrome (NBCCS). Patients with NBCCS are younger at OKC diagnosis than those with nonsyndromic OKC (NS-OKC). The purpose of this study was to determine the prevalence of undiagnosed NBCCS in children who present with an OKC and to assess differences in demographic and presenting features between children with NBCCS and those with NS-OKC.
Materials and Methods
This study is a retrospective case series of children with an OKC presenting to Boston Children’s Hospital (Boston, MA) from 2007 through 2018. To be included, patients had to be no older than 18 years and have a newly diagnosed OKC. Patients were excluded if they had previous or recurrent OKC or NBCCS diagnosis. Records were reviewed for age at presentation, gender, number and location of OKCs, treatment, recurrence, family history, and clinical features consistent with NBCCS. Descriptive data were summarized.
Results
The sample included 50 patients (27 boys) diagnosed with an OKC at a mean age of 11.7 years (range, 2 to 18 yr); 36% (n = 18) with NBCCS and 64% (n = 32) with NS-OKC. NBCCS diagnosis was made in 8 of 18 patients (44%) because of a family history at presentation, and in 10 patients (56%) the diagnosis was made by genetic testing or documentation of diagnostic criteria. Eight of 18 patients (44%) with undiagnosed NBCCS presented with a single OKC. Patients with NBCCS were significantly younger at presentation (NBCCS, 9.3 yr; NS-OKC, 13.0 yr), had more cysts at time of diagnosis (NBCCS, 1.7; NS-OKC, 1.0; P < .05), had more maxillary cysts (NBCCS, 13; NS-OKC, 11), and had a higher recurrence rate (P < .05).
Conclusion
Given the prevalence of undiagnosed NBCCS in children with OKC, clinicians should have a low threshold for referral for complete examination or genetic testing in children with even a single OKC.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Sialadenitis May Be Associated With an Increased Risk for Osteoradionecrosis: A Nationwide Population-Based Cohort Study
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: August 8, 2018; Accepted: January 28, 2019; Published online: February 05, 2019
Purpose
The impact of sialadenitis on osteoradionecrosis (ORN) is controversial. The aim of this study was to determine the association between sialadenitis and ORN.
Materials and Methods
Participants were derived from the Taiwanese Longitudinal Health Insurance Database. From January 1, 2000 to December 31, 2008, cases of sialadenitis (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 527.2, 527.3, 527.5 to 527.7, 527.9, and 710.2) and ORN (ICD-9-CMcodes 526.89, 526.5, 730.0, and 730.1) were identified. Different treatment modalities, including surgery versus medicine, were used to distinguish the severity of sialadenitis. The primary predictor variable was sialadenitis. The secondary predictor variable was severity of sialadenitis. The primary outcome variable was time to developing ORN. Other study variables were grouped for age, gender, risk factor, and medical treatment. Cox proportional hazard regression was used to investigate the associations between sialadenitis and ORN after adjusting for statistical confounders.
Results
The sample was composed of 47,385 patients with a mean age of 46.6 years (standard deviation, 19.9 yr) and 37.2% were men. Twenty percent had a diagnosis of sialadenitis and 1.13% had a diagnosis of ORN. Sialadenitis was associated with an increased risk of ORN (hazard ratio [HR] = 1.93; 95% confidence interval [CI], 1.61-2.31; P < .0001). After adjustment for confounders, sialadenitis was associated with ORN (multivariable HR = 1.83; 95% CI, 1.52-2.19; P < .0001). Severity of sialadenitis was associated with an increased risk of ORN; risks for ORN were 1.79 (95% CI, 1.49-2.16; P < .0001) and 3.52 (95% CI, 1.67-7.44; P < .001) in patients with mild and serious sialadenitis, respectively, compared with the no-sialadenitis cohort. For the joint effect of ORN between sialadenitis and malignancy type, patients with sialadenitis had 11.6-fold risk for ORN (95% CI, 5.58-23.9) compared with patients without malignancy.
Conclusions
Sialadenitis markedly increased the risk to develop ORN. The severity of sialadenitis was positively correlated with the incidence of ORN.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Laryngeal Spindle Cell/Pleomorphic Lipoma: A Case Report. An In-Depth Review of the Adipocytic Tumors
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: December 20, 2018; Accepted: January 28, 2019; Published online: February 06, 2019
Spindle cell and pleomorphic lipomas (SC/PLs) are a rare form of lipomatous tumors. They typically occur as a slow-growing localized mass in the subcutaneous fatty tissue of the posterior neck, back, and shoulders. This benign variant represents less than 1.5% of all lipomas and is relatively uncommon in the head and neck area. A manifestation in the larynx is even rarer. Unlike other anatomic locations, laryngeal lipomas can pose life-threatening symptoms secondary to acute obstruction of the upper aerodigestive tract. This report presents a case of a large SC/PL of the larynx associated with hoarseness, dysphagia, globus sensation, and neck fullness. The tumor was successfully removed through an anterior transcervical approach with infrahyoid myotomy. The authors review the literature concerning head and neck adipocytic tumors with spindle cells and discuss the difficulties in distinguishing SC/PLs from liposarcomas. To the best of the authors’ knowledge, this is the first case to be reported in the oral and maxillofacial surgery literature.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
A Case of Castleman Disease With Recurrence in the Neck: Case Report and Literature Review
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: December 13, 2018; Accepted: January 23, 2019; Published online: February 05, 2019
Castleman disease (CD) is a rare lymphoproliferative disorder with an uncertain etiology. It is necessary to review known cases because the possibility of CD is easy to overlook in the clinical diagnosis.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
First Case of Cutaneous Orbital Abscess Caused by Gemella: A Case Report and Review of the Literature
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: January 2, 2019; Accepted: January 28, 2019; Published online: February 05, 2019
This is the first report of an orbital abscess caused by Gemella bergeri, uncommonly identified in cardiac valvular infections. Through matrix-assisted laser desorption-ionization time-of-flight mass spectrometry (MALDI-TOF MS), microbial identification and speciation resulted in timely identification and appropriate management. Successful management includes accurate microbial identification, incision and drainage, and broad-spectrum antibiotics.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Evaluation of Mandible Fractures in Patients With Sickle Cell Anemia—A Nationwide Study
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 11, 2018; Accepted: December 27, 2018; Published online: January 02, 2019
Purpose
Sickle cell anemia is the most commonly inherited blood disorder in the United States. Despite its prevalence, clinicians know little about the extent of its impact on orofacial manifestations.
Materials and Methods
All patients with diagnoses of mandible fracture and sickle cell anemia admitted from 2004 through 2014 were identified using the National Inpatient Sample. Patient demographics, fracture regions, and complications were characterized by descriptive statistics.
Results
Fifty-one of 48,464 patients admitted for mandible fracture had sickle cell anemia. The mean age of the identified patients was 25 years (range, 4 to 58 yr). Of all admitted patients, mandible angle fracture was the most common (19%), followed by fracture of the body of the mandible. Seventy-five percent of cases reviewed were treated with open reduction and internal fixation.
Conclusions
Most mandible fractures in patients with sickle cell anemia were located in the angle of the mandible. Complications were minimal and outcomes were satisfactory. Aseptic necrosis of the jaw was a frequent complication of mandible fracture in patients with sickle cell anemia. These results provide clinicians with a better understanding of the distribution and hospital course of patients with sickle cell anemia and facial fractures.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Frequency of Cervical Spine Injuries in Pediatric Craniomaxillofacial Trauma
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 27, 2018; Accepted: February 19, 2019; Published online: February 27, 2019
Purpose
In pediatric patients with craniomaxillofacial (CMF) trauma, evaluation for cervical spine injury (CSI) is critical, but there are no studies investigating CSI in this unique population. The aim of this study was to measure the frequency of CSI in the pediatric CMF fracture population.
Materials and Methods
A retrospective cohort study of all pediatric patients who presented to the Johns Hopkins Hospital Emergency Department (Baltimore, MD) with CMF fractures were examined for concurrent CSIs. Patient charts were reviewed for mechanism of injury, type and level of CSI, type and location of CMF fracture patterns, and overall outcome. Data were analyzed for correlation and statistical relevance.
Results
A total of 2,966 pediatric patients (1,897 boys [64.0%]; age range, 0 to 15 yr; average age, 7 ± 4.73 yr) were identified from 1990 to 2010 to have CMF fractures. Of these patients, only 5 children were found to have concomitant CSIs (frequency, 0.169%). The frequency of CSI in patients with CMF fracture and deciduous, mixed, and permanent dentition was 0, 0.307, and 0.441%, respectively. Of the 5 identified cases, 4 had concomitant middle-third facial skeletal fracture, 4 had concomitant upper-third cranial skeletal fracture, and 2 had concomitant lower-third cranial skeletal fracture.
Conclusion
CSIs in pediatric patients with CMF fracture are rare (frequency, 0.169%); this is considerably lower than the reported ranges in adults (3.69 to 24%). No child with deciduous dentition was found to have a CSI. The lack of CSI in deciduous patients with CMF fracture could be explained by the anatomic differences between pediatric and adult cervical spines and supports conservative imaging for children in this age group (level of evidence, III).
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Relationship Between Nasal Fracture and Blowout Fracture: Can Nasal Fracture Be a Predictor of Blowout Fracture?
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: June 19, 2018; Accepted: September 5, 2018; Published online: September 12, 2018
Purpose
Nasal and blowout fractures are the most common injuries from craniomaxillofacial trauma. Nasal fractures are easily diagnosed by clinical signs, such as pain and crepitus. However, blowout fractures are frequently asymptomatic and are easy to miss without computed tomographic (CT) scanning. This study analyzed the relation between the 2 fracture types to determine whether nasal fracture could be used as a predictor of blowout fracture.
Materials and Methods
CT scans of 1,368 patients who underwent reduction surgery for nasal fracture were retrospectively reviewed. The pattern of nasal fractures (n = 1,368) was classified as frontal or lateral according to the direction of impact. Blowout fractures (n = 297) were classified into 3 types according to the position of the fracture: medial, inferior, or inferomedial wall. After calculating the number of patients in each group, the relation between nasal and blowout fracture types was statistically analyzed.
Results
Of 305 patients with frontal-type nasal fractures, the incidence of medial, inferior, and inferomedial wall fracture was 26, 7, and 9, respectively. Of 1,063 patients with lateral-type nasal fractures, the incidence of medial, inferior, and inferomedial wall fracture was 118, 75, and 62, respectively. Medial wall fracture was most common in the 2 nasal fracture groups and showed a higher frequency in the lateral-type group.
Conclusions
This study showed a strong relation between nasal fractures and medial wall blowout fractures. If nasal fracture is suspected, especially the lateral type, then thorough examination for medial wall blowout fracture, with a high index of suspicion, should be performed.
© 2018 Published by Elsevier Inc.
Evaluation of the Effect of Bioresorbable Plates and Screws in the Treatment of Condylar Fractures, Assisted by Digital Preoperative Planning
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 29, 2018; Accepted: February 5, 2019; Published online: February 12, 2019
Purpose
Although bioresorbable materials have begun to be applied in the clinic, they are used primarily in children with fractures; thus, there are few reports of their application for treatment of condylar fractures. This study evaluated the effect of the application of bioresorbable plates and screws for patients with condylar fractures, assisted by digital preoperative planning.
Materials and Methods
This was a prospective interventional study. The sample was composed of 46 patients treated at the School of Stomatology of the China Medical University (Shenyang, China) from October 2016 through May 2018 for condylar fractures alone or in combination with other facial fractures. All patients underwent confirmatory preoperative computed tomography (CT) to obtain Digital Imaging and Communications in Medicine (DICOM) format data for preoperative designing. By digital designing, the authors confirmed operative plans for each patient. All 46 patients underwent bioresorbable osteosynthesis and underwent repeat CT on postoperative day 3. Postoperative clinical assessments included postoperative positions of the fracture segments, maximal mouth opening, lateral excursion movements, occlusal status, and patient satisfaction. These variables were used to assess postoperative efficacy.
Results
The sample was composed of 46 patients who had open reduction with internal fixation on 52 sides. At the 3-month follow-up visit, the proportions of patients who were satisfied with the results and who achieved stable occlusion, appropriate maximal mouth opening, and flexible lateral excursion movement were 97, 100, 66, and 95%, respectively. One patient sustained postoperative displacement of a condylar fracture fragment, as confirmed by repeated CT. He was lost to follow-up at 3 months postoperatively.
Conclusion
The results of this study suggest that open reduction treatment of condylar fractures implanted with bioresorbable materials in combination with digital preoperative designing is an effective method for managing patients in clinical practice.
© 2019 Published by Elsevier Inc.
Two-Year Postoperative Upper Airway Cone-Beam Computed Tomographic Outcomes Based on a Verified Upper Airway Analysis Following Bimaxillary Orthognathic Surgery
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 29, 2018; Accepted: February 18, 2019; Published online: March 04, 2019
Purpose
Upper airway (UA) assessment after orthognathic surgery should rely on a verified method of UA analysis. Therefore, the authors applied a new validated UA evaluation method to determine the effect of bimaxillary surgery (BMS) on UA parameters and hyoid bone and epiglottis displacement evaluated immediately and 2 years after surgery.
Materials and Methods
A retrospective cohort study was implemented of patients without obstructive sleep apnea who had undergone BMS for maxillomandibular deficiencies. A new validated UA cone-beam computed tomographic (CBCT) analysis, based on stable anatomic landmarks, was applied to CBCT scans acquired before initiation of treatment (T0), immediately after surgery (T1), and 2 years postoperatively (T2). A quality assessment was performed before analysis. The primary predictor variable consisted of time points during treatment (T0, T1 and T2), and UA volumes, cross-sectional area (CSA), and hyoid bone and epiglottis displacement were the outcome variables. Descriptive statistics and t test were performed and the P value was set at .05.
Results
Fifty patients (16 men and 34 women) with a mean age of 25.7 ± 8.2 years at time of surgery were included. CBCT scans were acquired at T0 (20 ± 9 months before surgery), T1 (14 ± 2 days after surgery), and T2 (30 ± 6 months after surgery). Immediately after surgery (T1 vs T0), BMS resulted in a statistically relevant UA volume increase of 26%. At 2-year follow-up (T2 vs T0), UA volume showed a statistically relevant increase by 20%. CSA increased by approximately 26 and 19% (P < .001) at T1 versus T0 and T2 versus T0, respectively. Two years after surgery, epiglottis displacement was 2 mm (P < .001) and hyoid bone displacement was 3 mm (P < .001) in a cranial direction and hyoid bone anterior displacement measured 3 mm (P < .001).
Conclusions
Based on an objective, standardized, and validated CBCT UA analysis, BMS was associated with increased UA volume and CSA measures evaluated immediately and 2 years after surgery.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Surgery-First and Orthodontic-First Approaches Produce Similar Patterns of Condylar Displacement and Remodeling in Patients With Skeletal Class III Malocclusion
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 25, 2018; Accepted: January 31, 2019; Published online: February 12, 2019
Purpose
Condylar displacement and remodeling are critically involved in occlusal and skeletal stability after orthognathic surgery. The aim of the present study was to characterize condylar displacement and surface remodeling after bimaxillary orthognathic surgery in adult patients with skeletal Class III malocclusion treated by the surgery-first approach (SFA) or the orthodontic-first approach (OFA).
Materials and Methods
This retrospective cohort study recruited adult patients with mandibular hyperplasia treated with SFA or OFA. Simultaneous Le Fort I osteotomy for maxillary advancement and bilateral sagittal split ramus osteotomy for mandibular setback were performed in all patients. Original cone-beam computed tomographic data before surgery (T0), immediately after surgery (T1), and 12 months postoperatively (T2) were collected and reconstructed for 3-dimensional (3D) quantitative analyses. Three-dimensional condylar displacement and remodeling after SFA and OFA were characterized and statistically compared by Mann-Whitney U test and χ2test. The significance level was set at a P value less than .05.
Results
Twenty-four (male-to-female ratio, 1:2; mean age, 21.2 yr) and 20 (male-to-female ratio, 1:1; mean age, 23.1 yr) patients were enrolled in the OFA and SFA groups, respectively. Condylar inferolateral displacement with inward and anterior rotations from T0 to T1 and return movements from T1 to T2 were observed regardless of treatment approach. Significantly greater amount of 3D bodily shift immediately after surgery (2.04 ± 1.05 mm in SFA group vs 1.22 ± 0.66 mm in OFA group; P < .05) and downward movement 1 year after surgery were observed in the SFA versus OFA group. Bone resorption in the condylar surface was prevalent and predominant in its lateral areas, whereas bone formation was frequently observed in the anteromedial area in the SFA (45%) and OFA (42.9%) groups.
Conclusions
Similar patterns of 3D condylar displacement and surface remodeling were observed in patients treated with SFA or OFA.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
An Updated Protocol for the Treatment of Condylar Hyperplasia: Computer-Guided Proportional Condylectomy
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: October 25, 2018; Accepted: February 5, 2019; Published online: February 14, 2019
Purpose
To present an updated protocol for proportional condylectomy in which virtual surgical planning and 3-dimensional (3D) printing allow precise definition of the osteotomy level.
Materials and Methods
Three-dimensional mirroring was performed to generate a virtual replica of the healthy hemimandible, which was subsequently aligned and overlapped with the actual mandible to estimate the level for condylectomy. A custom-fitted 3D printed surgical guide was modeled for the condylar head to reproduce the virtual plan in the surgical scenario. The updated protocol for computer-guided condylectomy was applied to 7 patients.
Results
All patients were followed for 12 months. Surface deviation color maps showed a strong correspondence between the virtually calculated condylectomy and the surgical outcome achieved with the aid of the surgical guide. No cases of condylar hyperplasia recurrence were observed.
Conclusion
An updated protocol based on accurate 3D analysis was performed by virtual surgical planning and 3D printing. Virtual surgical planning allows the precise definition of the level of condylectomy, and custom-made 3D printed cutting guides are useful to reproduce virtual measurements during surgical maneuvers.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Esthetic Rhinoplasty in the Multiply Operated Nose
Behnam Bohluli, DMD, FRCD(CA)∗,Correspondence information about the author DMD, FRCD(CA) Behnam BohluliEmail the author DMD, FRCD(CA) Behnam Bohluli
Correspondence information about the author DMD, FRCD(CA) Behnam BohluliEmail the author DMD, FRCD(CA) Behnam Bohluli
Visiting Professor, Department of Oral and Maxillofacial Surgery, University of Toronto, Toronto, ON, Canada
Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 19, 2018; Accepted: February 26, 2019; Published online: March 07, 2019
Purpose
The present study assessed the most common deformities in often-revised noses and their predictable surgical treatments.
Patients and Methods
This retrospective case series was designed to review different aspects of patients with rhinoplasty who had more than 2 failed previous rhinoplasties. The main requests of patients, number of operations, and final surgical plan for management of these deformities were reviewed and analyzed.
Results
This study included 38 patients (27 women, and 11 men) who underwent multiple (2 to 10) unsuccessful rhinoplasties before being operated on by the author from 2011 to 2016. Pinch deformity (14 patients), breathing problems (13 patients), and irregularities were the most common complaints. The conchal cartilage (31 patients) and fascia (19 cases) were the most common graft donor sites in definitive treatments.
Conclusion
The present study shows that multiple failed rhinoplasties can be properly corrected. Effective management of these patients is best started after a comprehensive preoperative assessment. Then, a conservative predictable approach can be used to overcome the flaws of previous surgeries.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
A Straightforward Technique to Repair a Residual Oronasal Fistula in Bilateral Cleft Lip and Palate Patients
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Noel Ye Naung, BDS, Higher GradDipClinSc (OMFS), MSc (OMFS) †,∗,Correspondence information about the author BDS, Higher GradDipClinSc (OMFS), MSc (OMFS) Noel Ye NaungEmail the author BDS, Higher GradDipClinSc (OMFS), MSc (OMFS) Noel Ye Naung
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Correspondence information about the author BDS, Higher GradDipClinSc (OMFS), MSc (OMFS) Noel Ye NaungEmail the author BDS, Higher GradDipClinSc (OMFS), MSc (OMFS) Noel Ye Naung
Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: October 20, 2018; Accepted: January 30, 2019; Published online: February 07, 2019
Purpose
An anterior palatal oronasal fistula in a bilateral cleft lip and palate is a challenging clinical dilemma. The purpose of this article is to present a 2-stage technique to repair the fistula in consistent fashion. The technique was developed to avoid more complicated procedures that had greater morbidity for larger oronasal defects that could not be treated in a single procedure.
Materials and Methods
This is a retrospective study performed over 15 years using this technique in a private practice setting. From 2002 to 2017, 15 7- to 12-year-old patients (11 boys and 4 girls) were treated. They were seen in a multispecialty clinic for anterior residual fistulae, and impressions were obtained. Then, they were scheduled for first-stage closing of the fistulae. Data were retrospectively analyzed. The first stage started with closing the central portion of the fistulae. For the second stage 6 months later, the residual nasoalveolar cleft was closed and grafted in standard fashion. The first stage involved posteriorly reflecting a full-thickness mucoperiosteal flap and inserting it into the palatal soft tissue and stabilizing the segment with a splint for 3 weeks. The premaxillary segment was left denuded.
Results
Fourteen of 15 patients (93%) had the central portion of the oronasal fistulae successfully closed. One patient had partial breakdown when the splint was prematurely removed at 2 weeks. The patient underwent successful closure by the same procedure at a later date. All patients had successful second-stage grafting of their nasoalveolar clefts.
Conclusions
An alternative technique is presented to treat clinically challenging oronasal fistulae. This 2-stage closure of a palatal fistula is straightforward, allows consistent closure of soft tissue defects, and avoids complex alternative procedures with serious surgical morbidities.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Maintenance of Segmental Maxillary Expansion: The Use of Custom, Virtually Designed, and Manufactured Palatal Appliances Without the Use of an Occlusal Splint
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 14, 2018; Accepted: March 12, 2019; Published online: March 25, 2019
Expansion of the maxilla using a segmental Le Fort I osteotomy is a routine and commonly used procedure in the treatment of dentofacial deformities. Although orthognathic surgery has seen tremendous advancement in technology, including virtual surgical planning and customized hardware, some room for advancement exists in the maintenance of surgical maxillary expansion. Traditionally, this has been accomplished with retention of a maxillary occlusal splint 4 to 8 weeks postoperatively. This article introduces some novel techniques to help maintain this expansion, including the intraoperative transpalatal archwire and custom palatal strap appliance in conjunction with autogenous bone harvest and grafting in lieu of using occlusal-based splints. The aim of these techniques is to improve postoperative patient comfort and surgical outcomes and shorten postoperative orthodontic treatment time.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Three-Dimensional Evaluation of the Postsurgical Stability of Mandibular Setback With the Surgery-First Approach: Comparison Between Patients With Symmetry and Asymmetry
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 12, 2018; Accepted: March 19, 2019; Published online: March 26, 2019
Purpose
The purpose of the present study was to evaluate the 3-dimensional postsurgical stability of mandibular setback with a surgery-first (SF) orthodontic treatment approach in patients with skeletal Class III malocclusions and facial asymmetry using cone-beam computed tomographic (CBCT) images.
Patients and Methods
Thirty-six patients who underwent mandibular setback with an SF approach for the correction of mandibular prognathism were enrolled in the present study. Patients were divided into symmetrical (n = 18) and asymmetrical (n = 18) groups according to their degree of menton deviation. CBCT images were acquired before surgery, 1, 6, and 12 months after surgery, and at the end of treatment. After reorienting of CBCT images using automatic volume-based registration, the position of the mandible at each time point was evaluated relative to its post-treatment position. MATLAB (MathWorks, Natick, MA) was used to represent all sequential changes in postoperative mandibular position. The increase in posterior vertical dimension at surgery was measured and then correlated with postsurgical mandibular stability.
Results
For up to 6 months after surgery, the position of the mandible differed considerably from its post-treatment position. At 12 months after surgery, the position of the mandible no longer differed substantially from its post-treatment position. The asymmetry group exhibited greater outward displacement of the proximal segment. The symmetrical and asymmetrical groups exhibited a positive correlation between postsurgical mandibular instability and the increase in posterior vertical dimension.
Conclusion
These results indicate that mandibular position stabilizes 12 months after surgery performed with an SF approach. It is necessary to consider mandibular forward movement from the increase in posterior vertical dimension in surgical occlusion during the treatment planning stage. Moreover, clinicians should maintain the surgical position of proximal segments during postsurgical orthodontic treatment at least until 12 months after surgery.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
The Feasibility of Using the Posterior Auricular Branch of the Facial Nerve as a Donor for Facial Nerve Reanimation Procedures: A Cadaveric Study
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: December 14, 2018; Accepted: February 28, 2019; Published online: March 13, 2019
Purpose
Facial nerve paralysis can result in critical complications, including those to the visual, respiratory, and digestive systems. The facial nerve has been reanimated using various nerves, but the posterior auricular nerve (PAN) branching off the facial nerve has not been explored for this purpose.
Materials and Methods
Ten sides from 6 fresh-frozen adult cadavers were used for dissection of the PAN to explore its potential as a donor for facial nerve reanimation. The facial nerve trunk (FNT) and PAN were consistently and readily identified by deep dissection using the tragal cartilage and tragal pointer as landmarks. The PAN was transected at the point of insertion of its innervated muscles. Its length and diameter were measured, and it was transposed anteriorly to the FNT and its 2 major extracranial divisions.
Results
The PAN was observed on all sides. Its available length was 27.11 ± 5.02 mm and its mean diameter was 0.85 ± 0.20 mm. In all specimens, the PAN readily reached the FNT and its 2 major divisions without tension.
Conclusion
No previous study has explored the use of the PAN as a donor for facial nerve reanimation. Based on the present cadaveric study, surgeons might consider it for this purpose.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Prognostic Impact of Postoperative Complications on Overall Survival in 287 Patients With Oral Cancer: A Retrospective Single-Institution Study
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 6, 2018; Accepted: January 17, 2019; Published online: January 25, 2019
Purpose
To investigate the relation between postoperative complications and long-term survival in patients with oral cancer after surgery and to explore the methods that improve survival rate through analyzing risk factors for postoperative complications.
Materials and Methods
This is a retrospective single-institution study of a cohort of 287 patients with oral cancer who underwent surgery at the Stomatological Hospital of the Chongqing Medical University (Chongqing, China) from January 1, 2007 through December 31, 2012.
Results
Postoperative complications occurred in 80 patients (27.9%). Patients with pulmonary complications or delirium had worse overall survival than those without these complications, whereas other postoperative complications, such as surgical site infection, postoperative bleeding, salivary fistula, and chylothorax, were not associated with overall survival. American Society of Anesthesiologists (ASA) status and tracheostomy were risk factors for postoperative pulmonary complications according to the Pearson χ2 test or multivariate analysis. Using the Pearson χ2 test, age, comorbidity, and ASA status were risk factors for the incidence of postoperative delirium. However, in multivariate analysis, only comorbidity and ASA status were identified as risk factors.
Conclusions
Postoperative pulmonary complications and postoperative delirium could be independent predictors of poorer long-term survival in patients with oral cancer. The risk factors for postoperative pulmonary complications and postoperative delirium could help identify patients who are at high risk and help clinicians take some actions to prevent them.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Oral Cancer Treatment Through the Ages: Part 1
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: August 14, 2018; Accepted: January 15, 2019; Published online: January 28, 2019
Purpose
Understanding how oral cancer treatment evolved can pave the way for future management. The literature holds an expansive collection of historical findings regarding oral cancer, yet the authors were unable to find a comprehensive review of oral cancer treatment throughout the ages.
Methods
A thorough literature review was carried out using multiple scientific databases and languages, as well as examination of historical archives. Articles were included for their relevance and their findings were assimilated.
Results
Part one of this article reveals a rich history of oral cancer treatment commencing in ancient times, with discussion of Egyptian, Greek and Roman practices, and travelling through the age of discovery to arrive at the dawn of scientific medicine in the 19th century.
Conclusion
Part one demonstrates how fundamental concepts of oral cancer were discovered, and the significant impact medical innovation had on the success of oral cancer treatment.
© 2019 Published by Elsevier Inc. All rights reserved.
Oral Cancer Treatment Through the Ages: Part 2
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: August 14, 2018; Accepted: January 15, 2019; Published online: January 28, 2019
Purpose
Understanding how oral cancer treatment evolved can pave the way for future management. The literature holds an expansive collection of historical findings regarding oral cancer, yet the authors were unable to find a comprehensive review of oral cancer treatment throughout the ages.
Materials
A thorough literature review was carried out using multiple scientific databases and languages, as well as examination of historical archives. Articles were included for their relevance and their findings were assimilated.
Results
Part two of this article considers the development of specific surgical concepts relating to head and neck cancer over the previous two centuries, including neck dissection and reconstruction, as well as exploration of non-surgical cancer therapies.
Conclusion
This paper demonstrates historical landmarks made in oral cancer treatment and the prominent figures who pioneered them, confirming that head and neck cancer surgeons of today have valuable lessons to learn from their previous counterparts.
© 2019 Published by Elsevier Inc. All rights reserved.
Management of Mandibular Osteomyelitis With Segmental Resection, Nerve Preservation, and Immediate Reconstruction
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: November 16, 2018; Accepted: January 23, 2019; Published online: January 30, 2019
Purpose
The purpose was to present our experience with management of mandibular osteomyelitis with segmental resection, nerve preservation, and immediate reconstruction with nonvascularized bone grafts.
Patients and Methods
We completed a retrospective analysis of 18 cases overseen by a single practitioner at a university medical center from June 2011 to July 2018. All patients had osteomyelitis and were treated with segmental mandibular resection, inferior alveolar nerve (IAN) preservation, and immediate reconstruction with autogenous bone graft from the tibia. Data obtained from medical records included the chief complaint at initial presentation, resection size, and IAN neurosensory recovery at 6 months, as well as descriptive statistics of the patient cohort. The university institutional review board granted this study exempt status.
Results
The patient cohort had a mean age of 50.9 years, ranging from 29 to 70 years, and included 11 female and 7 male patients. The mean follow-up time was 15 months. The most common chief complaint at initial presentation was pathologic fracture (39%), followed closely by abscess (33%). The average mandibular resection size of all patients was 8.1 cm (standard deviation [SD], 3.3 cm). The resection size measured 7.1 cm (SD, 2.6 cm) in patients with successful bone grafts (n = 15) and 13.1 cm (SD, 2.0 cm, P = .0016) in those with graft failure (n = 3). IAN neurosensory testing showed that 54% of patients had no meaningful recovery at 6 months, 25% had partial recovery, and 21% had full recovery. Finally, osteomyelitis was eliminated in all patients.
Conclusions
Segmental mandibular resection is an effective method for eradicating mandibular osteomyelitis. Furthermore, immediate reconstruction via nonvascularized grafts is successful in cases with large defects, with a mean defect size of 7.1 ± 2.6 cm. However, IAN-sparing surgery is not effective for preserving patient IAN function. Taken together, our findings show that mandibular resection with immediate reconstruction is a viable method in the treatment of mandibular osteomyelitis. This method removes infection and shortens the disease course.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Deep Parotid Lymph Node Metastasis Is Associated With Recurrence in High-Grade Mucoepidermoid Carcinoma of the Parotid Gland
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: December 27, 2018; Accepted: January 21, 2019; Published online: January 29, 2019
Purpose
The goal of the present study was to assess the association between intraparotid lymph node (IPN) metastasis and prognosis in high-grade mucoepidermoid carcinoma (MEC) of the parotid gland.
Patients and Methods
Patients with surgically treated primary high-grade MEC of the parotid gland were retrospectively enrolled. The association between IPN metastasis and clinicopathologic variables was analyzed using χ2 tests, and recurrence-free survival (RFS) rate was calculated by the Kaplan-Meier method; independent prognostic factors were evaluated by the Cox proportional hazards method.
Results
IPN metastasis was noted in 59 patients (48.4%), including 19 cases in the deep lobe and 47 cases in the superficial lobe of the parotid gland. IPN metastasis was statistically related to tumor stage and node stage regardless of the location of the metastasis in the deep or superficial lobe. Patients with superficial and deep lymph node metastasis had a low 5-year RFS rate of 11%. Cox model analysis reported that the status of IPN metastasis was an independent risk factor for recurrence.
Conclusions
IPN metastasis substantially decreases the RFS rate, especially when there is lymph node metastasis in the deep lobe of the parotid gland.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Is Lymph Node Ratio a Prognostic Factor for Patients With Oral Squamous Cell Carcinoma?
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: September 7, 2018; Accepted: January 20, 2019; Published online: February 01, 2019
Purpose
Lymph node ratio (LNR), defined as the ratio of positive resected lymph nodes (LNs) to the total number of resected LNs, predicts survival for some solid tumors. This study investigated the value of LNR in the prognosis and postsurgical management of oral squamous cell carcinoma (OSCC).
Materials and Methods
The authors designed a retrospective cohort study and enrolled a sample of patients who were diagnosed with OSCC and treated by neck dissection. The predictor was LNR and the outcome variable was overall survival (OS). Other variables were dissection type, postsurgical management, number of positive LNs, pN stage, nodal disease area, extracapsular spread, perineural invasion, vascular invasion, and lymph duct invasion. Differences in OS rate were analyzed by log-rank test. A Cox proportional hazards model was used to adjust for the effects of potential confounders. Differences with a P value less than .05 were considered statistically significant.
Results
In 95 patients with OSCC, the LNR cutoff value for predicting overall OS was 0.04 (area under the curve, 0.705; P = .010). There was a significant difference in OS when patients were stratified according to LNR (rate for low LNR, 90.5%; rate for high LNR, 68.8%; P = .014). Univariate analyses showed close correlations between OS and LNR, pT stage, number of positive LNs, and nodal disease area (levels IV and V). Cox multivariate analysis identified LNR (hazard ratio [HR] = 2.889; 95% confidence interval [CI], 1.032-8.087; P = .043) and area of nodal disease (levels IV and V; HR = 5.149; 95% CI, 1.428-18.566; P = .012) as independent predictive factors for OS. OS differed significantly between the high-LNR and low-LNR groups treated by surgery alone (P = .027).
Conclusions
As a predictive factor, high LNR (>0.04) was associated with decreased survival, and intensive adjuvant therapy could improve the prognosis for patients with high LNR.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Surgical Treatment of Primary Parapharyngeal Space Tumors: A Single-Institution Review of 28 Cases
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Received: October 29, 2018; Accepted: March 3, 2019; Published online: March 13, 2019
Purpose
This study evaluated the surgical treatment of tumors arising from the parapharyngeal space (PPS) in a single-center setting.
Materials and Methods
This retrospective study was conducted with 28 patients who underwent surgery for primary PPS tumors from 2011 to 2018. Patient clinical features, histologic tumor type, surgical approach, complications, and follow-up data were evaluated.
Results
All patients underwent surgery in this series. The transmandibular approach was most frequently performed (35.7%), followed by the transcervical (28.6%), transparotid (17.9%), and transoral (17.9%) approaches. A surgical navigation system was applied to the surgery of 4 cases with superior PPS tumors. The mean surgical duration of these cases (205.0 minutes) was shorter than that of cases without surgical navigation, and the mean maximum size (MMS) of tumors (5.8 cm) was larger (P < .01). Eleven different tumor types were diagnosed after surgery (78.6% benign and 21.4% malignant). For postoperative complications, there were 10 cases of lower lip numbness, 4 of facial nerve dysfunction, 2 of trismus, and 1 each for the remaining types. During 4- to 81-month follow-up, 27 patients had no recurrence, metastasis, or death and 1 patient was lost to follow-up.
Conclusion
The histopathologic diagnoses were consistent with those of previous reports. Surgical resection is the main treatment for PPS tumors, with relatively low rates of recurrence and death. For superior PPS tumors, the surgical navigation system can substantially shorten the operative duration and is more suitable for larger tumors.
© 2019 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
News and Announcements
The Basic Emergency Airway Management (BEAM) module will be available for the first time at an AAOMS Annual Meeting during two sessions September 21 in Boston, MA.
Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
Journal of Oral and Maxillofacial Surgery
(ISSN 0278-2391) is published monthly by Elsevier Inc, for the American Association of Oral and Maxillofacial Surgeons, 360 Park Avenue South, New York, NY 10010-1710. Business Office: 1600 John F. Kennedy Blvd, Ste 1800, Philadelphia, PA 19103-2899. Periodicals postage paid at New York, NY and additional mailing offices.
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Journal of Oral and Maxillofacial Surgery, Volume 77, Issue 7
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