Recurrent central odontogenic fibroma in a patient with nevoid basal cell carcinoma syndrome: case report and in vitro analysis.

OBJECTIVE: Central odontogenic fibromas (COF) are rare, benign tumors derived from dental mesenchymal tissue that may occur in the maxilla or mandible. This report describes primary and recurrent COF in the mandible of a patient with nevoid basal cell carcinoma syndrome (NBCCS). STUDY DESIGN: A 36-year-old African American male presented with a COF and its recurrence 17 months later. Tissue pieces were obtained from both occurrences with IRB-approved signed consent. Collected tissue pieces were dissected; one portion was formalin-fixed and paraffin-embedded, and the other was cultured for the isolation of cell populations from the primary (COdF-1) and recurrent (COdF-1a) tumors. Quantification real-time polymerase chain reaction (qRT-PCR), immunohistochemistry, and DNA sequencing were used for gene and protein analysis of the primary tumor and cell populations. RESULTS: Histopathologic analysis of the tumor showed sparse odontogenic epithelial cords in fibrous connective tissue, and qRT-PCR analysis of tumor and cell populations (COdF-1 and COdF-1a) detected VIM, CK14, CD34, CD99 and ALPL mRNA expression. Protein expression was confirmed by immunohistochemistry. CD34 expression in primary tissues was higher than in tumor cells due to tumor vascularization. DNA sequencing indicated the patient had PTCH1 mutations. CONCLUSIONS: Histopathology, mRNA, and protein expression indicate the rare occurrence of COF in a patient with mutated PTCH1 gene and NBCCS.

Does the Levasseur-Merrill Retractor Provide Reliable In Vivo Guidance for the Intraoral Vertical Ramus Osteotomy?

PURPOSE: Levasseur-Merrill retractor (LMR) utilization during the intraoral vertical ramus osteotomy (IVRO) helps initiate the osteotomy approximately 7 mm from the posterior border of the mandible, preventing damage to the inferior alveolar nerve. The purpose of this in vivo study is to evaluate the IVRO placement and the risk of neurosensory deficit (NSD) while using the LMR. METHODS: This prospective case series was conducted at a single tertiary care center. Medical records were reviewed for medical and demographic information. Inclusion criteria were as follows: underwent the IVRO procedure by a single provider from June 2020 to June 2022 and postoperative cone beam computed tomography images. Exclusion criteria were as follows: age less than 16 years, previous mandibular osteotomies, inadequate clinical documentation, or follow-up. The primary outcome variables included the proximal segment width and proximity of the IVRO to the inferior alveolar foramen. The secondary outcome variable was NSD as measured subjectively by 2-point discrimination, sharp versus dull touch, and light touch with von Frey filaments. RESULTS: The 26 subjects (42 operated sides) were 96% female, with an average age of 30.1 years (range 17-54 years). The mean proximal segment width was 10.3 ± 1.7 mm (95% confidence interval: 9.77, 10.83). The mean distance from the posterior border of the inferior alveolar foramen (IAF) to the osteotomy was -0.89 ± 1.7 mm (95% confidence interval: -1.43, -0.35), with negative numbers indicating violation of the IAF. IAF and full bony canal violation occurred in 61.9% and 4.8% of operated sides, respectively. NSD at 6 months postoperatively occurred in the 2 sides that experienced full bony canal violation. CONCLUSIONS: The LMR did not consistently guide the IVRO position within 7 mm from the posterior border of the mandible as previously thought and allows for frequent violation of the IAF. Long-term NSD of the inferior alveolar nerve was infrequent and correlated with violation of the full bony canal.

An Evaluation of Jaw Tracking Movements in Patients with Total Joint Replacements versus a Control Group.

Background and Objectives: One form of treatment for degenerative temporomandibular joint diseases such as osteoarthritis, rheumatic arthritis, TMJ ankylosis, and condylar resorption is total joint replacement. The aim of this study was to examine the function of the temporomandibular joint after prosthetic joint replacement. Materials and methods: Fifteen patients with unilateral or bilateral TMJ total joint replacements and 15 healthy controls were evaluated via a SICAT JMT+ device. This non-invasive system measures 3D position and linear movements in all degrees of freedom and allows undisturbed functional mandibular movements to provide a quantitative evaluation. In addition, a TMJ questionnaire consisting of the subjective symptoms was also obtained. To date, no similar studies have been cited in the literature. Results: Mandibular movements after prosthetic joint replacement were recorded during opening, closing, protrusion, and lateral excursive movements and were all significantly decreased compared to those of controls. In the treatment group, the maximum incisal opening was 33.46 ± 5.47 mm, left lateral movement was 1.91 ± 2.7 mm, right lateral movement was 1.74 ± 1.74 mm, and protrusive movement was 2.83 ± 2.05 mm. The p-value comparison study and control group indicated significant difference (p < 0.0001) between the two groups. The study group stated a high level of satisfaction with the total joint replacement. Conclusion: Within the limitations of the study, the following conclusions can be drawn: (1) TMJ replacement patients showed significantly limited jaw movements compared to the control group; (2) a small percentage of TMJ replacement patients still present low levels of pain but improved chewing ability and quality of life.

Complications of Dentoalveolar Surgery.

This article explores how to prevent and manage complications of dentoalveolar surgery. Many complications are avoidable. Surgical skills and knowledge of anatomy play an important role in prevention of complications. Prevention starts with detailed history and physical examination of the patient. Key to perioperative management of patients is risk assessment. Without a proper history and physical examination, the clinician is unable to assess the risk of performing surgery and anesthesia for each patient. Some illnesses and medications increase the risk of complications. The following complications are discussed: alveolar osteitis, displacement, fracture, hemorrhage, infection, nonhealing wound, oroantral communication, swelling, and trismus.

Outcomes and Survivorship of Biomet Microfixation Total Joint Replacement System: Results From an FDA Postmarket Study.

PURPOSE: In February 2011, the Food and Drug Administration issued a postmarket surveillance order to all manufacturers of temporomandibular joint (TMJ) implants in the United States. The objective of the present study was to measure implant subsequent surgical intervention (SSI) among patients who had undergone TMJ reconstruction with the Biomet TMJ replacement system (Zimmer Biomet, Warsaw, IN). MATERIALS AND METHODS: A prospective observational study was conducted by sending a questionnaire to patients who had received a Biomet TMJ replacement system from 1995 to 2010 in the United States. The questionnaire was sent annually from 2012 to 2015. The primary endpoint was the SSIs. SSIs included both device removal and reoperations. Kaplan-Meier survival analysis was used to determine the survivorship, and Cox proportional hazard regression analysis was performed to evaluate the preoperative diagnosis and SSI. RESULTS: The mean age at implantation was 46.6 ± 12.5 years, with a gender distribution of 86.1% female. Data from 499 joints in 319 subjects were collected as a part of the survey. The mean follow-up time was 8.6 ± 3.9 years (range, 2-20 years). The first SSI frequency was 11.2% (4.2% removal rate and 7.0% reoperation rate). The survivorship rate (Kaplan-Meier) was 96% at 3 years, 94% at 5 years, and 86% at 10 years. The mean interval to failure using a survival function to determine the time to SSI (Greenwood's formula) was 13.5 ± 0.193 years. The most common causes of SSI included adhesion removal (2.6%; 13 of 498), heterotopic bone/ankylosis (2.0%; 10 of 498), and infection (1.6%; 8 of 498). CONCLUSIONS: The results from the present study are consistent with the reported survivorship rates for other orthopedic devices (5-year survival for total hip or knee arthroplasty, 95.9 and 97.2%, respectively). The etiology of SSIs in the Biomet TMJ replacement system was primarily secondary to biologic failure (ie, adhesions, heterotopic bone, and infection).

Team approach in the management of revision surgery to correct bilateral temporomandibular joint replacements.

This case report describes the successful second surgical treatment of a 26-year-old white female patient with a retrognathic mandible and previous bilateral total joint prostheses placement. The patient had previously presented with bilateral idiopathic condylar resorption (ICR) which caused clockwise mandibular rotation and resulted in anterior open bite and a retrognathic mandible. The patient had undergone definitive corrective for the ICR where condylectomies were performed bilaterally. In addition, total joint prostheses using 'stock joints' were used to restore the condyle and glenoid fossa on both sides. Although the previous surgery corrected the anterior open bite and restored the condyles, the patient was still suffering from joint symptoms (significant pain), restricted mandibular movements, increased overjet (12 mm) and a retrognathic mandible. The treatment plan included a combined orthodontic surgical approach: (1) bimaxillary orthognathic surgery: a surgical procedure on the mandible to reposition the prosthetic joints and correct the mandible position, and a segmental LeFort I to expand the maxilla; and (2) post-surgical orthodontics treatment to detail the occlusion. At the end of the treatment, good aesthetic and functional results were obtained with the cooperation of two specialties. This case emphasises the importance of three-dimensional planning and multidisciplinary treatment when addressing complex jaw movements. It also emphasises the importance orthodontic planning and collaboration with the orthodontist.

An Institutional Review: Which Metrics Correlate With a Successful United States Medical Licensing Examination Step 1 Score?

PURPOSE: Since the introduction of the Comprehensive Basic Science Examination (CBSE) as an entrance examination in 2012, no studies have been performed correlating its relationship with passing rates on United States Medical Licensing Examination (USMLE) Step 1 in dental students. This study was designed to determine the impact of the CBSE score, dental grade point average (GPA), and undergraduate GPA on USMLE Step 1 performance and develop a CBSE cutoff score that correlates with a passing USMLE score. MATERIALS AND METHODS: A single-blinded, retrospective, cross-sectional study was designed. Data were collected from University of Alabama at Birmingham oral-maxillofacial surgery residents who had matriculated from 2014 to 2018. The primary predictor variable was the CBSE score. The primary outcome variable was the USMLE Step 1 score. Additional predictor variables included undergraduate and dental school GPAs. Bivariate statistics were calculated using a 2-tailed Pearson correlation (P = .05). Confounders were investigated using multivariate linear regression (P = .05). A bivariate linear regression was created using the variables of CBSE and USMLE scores. RESULTS: Dental school GPA and CBSE score correlated with USMLE Step 1 score (P < .05). Bivariate linear regression between CBSE and USMLE scores yielded a predictive equation of USMLE score = 2.02 × CBSE score + 66.2 (R2 = 0.30). When second-attempt scores were included, this equation became USMLE score = 2.08 × CBSE score + 67 (R2 = 0.49). The positive predictive value for a CBSE cutoff score of 61 reached 100% on repeated USMLE attempts. CONCLUSIONS: A CBSE score for dental students of 61 or greater correlates with a passing USMLE score and should be implemented to screen for dual-degree oral-maxillofacial surgery candidates.

A comprehensive treatment approach for idiopathic condylar resorption and anterior open bite with 3D virtual surgical planning and self-ligated customized lingual appliance.

INTRODUCTION: We report the successful treatment of a 38-year-old woman with bilateral idiopathic condylar resorption and anterior open bite. She had incompetent lips, a gummy smile, increased lower facial height, high mandibular plane angle, skeletal and dental Class II malocclusion with mild mandibular crowding, increased overjet, and mandibular midline deviation to the right. METHODS: The treatment plan included: (1) presurgical alignment and leveling of the teeth in both arches; (2) jaw motion tracking (JMT) to detect mandibular movement; (3) 3-piece maxillary osteotomies with mandibular reconstruction and bilateral coronoidectomies; and (4) postsurgical correction of the malocclusion. The orthodontic treatment was performed with the use of custom lingual braces and clear brackets and the orthognathic surgery was planned with the use of virtual surgical planning. RESULTS: The idiopathic condylar resorption and anterior open bite were treated, crowding was eliminated in the lower anterior segment, correction of skeletal and dental Class II malocclusion was obtained, mandibular plane angle was reduced, and facial profile improved. CONCLUSIONS: The results suggest that esthetic and functional results can be achieved with the cooperation of 2 specialties and with the use of state-of-the-art technology.

Managing Bone Grafts for the Mandible.

Bone grafting has become an integral part of implant dentistry. To achieve a predictable long-term outcome for osseointegrated implants, a sufficient volume and quality of alveolar bone must be present at implant recipient sites. Resorption of the alveolar ridge and postsurgical or post-traumatic defects of the residual alveolar bone can prevent ideal placement of a dental implant. Thus, in many cases, alveolar bone grafting is the real challenge in implant reconstruction. This article will discuss the various techniques and graft materials for alveolar ridge reconstruction of the mandible. It also compares and contrasts these techniques by reviewing the current literature.

Advancements in Maxillofacial Trauma: A Historical Perspective.

For the 75th anniversary of the Journal of Oral and Maxillofacial Surgery, the authors were asked to review the past and examine advancements in the management of facial trauma. Several important advances in the management of maxillofacial trauma have resulted in improved outcomes. These include the development of high-resolution computed tomography, improved classification schemes, rigid fixation techniques, improved biomaterials, soft tissue resuspension, and primary bone grafting. Further advances in outcomes have occurred with the use of microsurgical techniques, free tissue transfer techniques, virtual surgical planning, endoscopic techniques, and surgical navigation. Historic treatments and these important advances are discussed.

The use of three-dimensional evaluation in the management of a complex patient with mandibular fracture: a 5-year evaluation.

AIM: The aims of this study were to diagnose and evaluate a case of severe condylar fracture followed up over 5 years using three-dimensional imaging for soft tissue and hard tissue. METHODS: The patient underwent reconstruction with an autogenous rib graft to correct the resorbed left condyle secondary to a previous fracture and to balance her facial asymmetry. Orthodontic treatment is ongoing to equilibrize the occlusion and dentofacial complex. A stereo-photogrammetric system (3dMDFace System) was used to capture the soft tissue image of the patient. In addition, a cone-beam computed tomography (Kodak 9500) was used for hard tissue acquisition. The resultant images were analyzed using Rapidform 6 (RP6) and 3dMDvultus three-dimensional software packages, for 3 time frames: before surgery (T1), 1 month after surgery (T2), and 8 months after surgery (T3). RESULTS: Using three-dimensional software to analyze the three-dimensional data, several findings were noted: (1) soft tissue compensation of the hard tissue deformity for the facial asymmetry was around 7 mm; (2) color mapping and histograms helped identify distinct facial differences represented by positive changes of the patient's face because of the mandible reconstruction at T1-T2 and the mandible moving to its normal position at T3-T4. CONCLUSIONS: Three-dimensional imaging provides more accurate information and virtual representation of the patient. This leads to better diagnosis and treatment planning. In addition, the preliminary results of this study showed supportive evidence for the use of rib grafts in children.

Reconstruction of acquired temporomandibular joint defects.

Various conditions are responsible for the development of acquired temporomandibular joint (TMJ) defects, the reconstruction of which represents a unique challenge, as the TMJ plays an important role in the functioning of the jaw including mastication, deglutition, and phonation. Autogenous reconstructions such as costochondral or sternoclavicular joint graft continue to be the best option in children, owing to their ability to transfer a growth center. In adults, alloplastic reconstructions are a safe and predictable option. Vascularized tissue transfers have also become a popular and reliable way to restore these defects.

Surgical navigation in reconstruction.

Navigational systems are paramount in solving today's traffic dilemmas, and have important applications in the human body. Current imaging must be diagnostic and is often dictated by the radiologist, but it is up to the surgeon to consider surgical procedures and to decide in which case surgical navigation (SN) has advantages. Knowledge of the surgical capabilities of SN is indispensable. The aims of this article are to support real-time image-guided SN, present routine and advanced cases with precise preoperative planning, and show the scientific capabilities of SN.

Autogenous and prosthetic reconstruction of the ear.

Injuries to the ear can result in partial or complete loss of the external ear. Resection of the external ear may be necessary secondary to malignant tumor or infection. This article discusses the diagnosis and management of acquired defects of the external ear. Because autogenous reconstruction is not always possible, both autogenous and prosthetic reconstruction are presented as well as the indications for both. This information should help guide the clinician in the decision-making process. In the hands of experienced clinicians, reconstruction of the external ear can result in an excellent outcome, with improved quality of life for the patient.

Review and recommendations for the prevention, management, and treatment of postoperative and postdischarge nausea and vomiting.

Patients have rated severe nausea to be worse than postoperative pain. The overall incidence of postoperative nausea and vomiting (PONV) is 25%-30% and can lead to delayed discharge and unanticipated hospital admission. After outpatient surgery, the overall incidence of postdischarge nausea has been reported to be 17% and of vomiting 8%, higher than nausea and vomiting reported during the procedure or recovery. Patients who experienced postdischarge nausea and vomiting (PDNV) were unable to resume normal daily activities as quickly. This paper addresses the frequency, pathophysiology and patient perception of PONV and PDNV and reviews antiemetics and adjunctive medications used for the prevention, management, and treatment of PONV and PDNV. For each, the indication, mechanism of action, adverse effects, drug interactions, and implications for oral surgery and outpatient sedation are provided. Because many antiemetics are available for prevention, management, and treatment of PONV and PDNV, optimal medication choices are important for each procedure and patient.

Use of recombinant bone morphogenetic protein 2 in free flap reconstruction for osteonecrosis of the mandible.

PURPOSE: Osteoradionecrosis of the mandible is a debilitating consequence of radiation therapy for head-and-neck malignancy. It can result in pain, bone exposure, fistula formation, and pathologic fracture. Recombinant human bone morphogenetic protein 2 (rhBMP-2) has shown promise in reconstruction of bone defects. The purpose of this study is to determine whether the addition of rhBMP-2 at the union of vascularized bone and native bone improves surgical outcomes in patients with osteonecrosis of the mandible. MATERIALS AND METHODS: This study was a retrospective analysis of patients who were treated between 2006 and 2010 for osteonecrosis of the mandible. Patients requiring definitive reconstruction after failure of a course of conservative management were included. Patients were divided into 2 cohorts depending on whether rhBMP-2 was used during the reconstruction. The primary outcome measure was defined as stable mandibular union. RESULTS: Seventeen patients were included. The development of malunion was similar in both groups (13% for rhBMP-2 group vs 11% for non-rhBMP-2 group). Infectious complications were similar between the groups (25% in rhBMP-2 group vs 56% in non-rhBMP-2 group, P = .33). The rates of hardware removal were similar for the 2 groups (33% in non-rhBMP-2 group vs 25% in rhBMP-2 group, P = .10). No cancer recurrences were observed in patients receiving rhBMP-2. CONCLUSIONS: The use of rhBMP-2 is safe in free flap reconstruction of the mandible, but its ability to significantly improve patient outcomes, as measured by rates of malunion, reoperation, or infection, is still unknown.

Revisiting the supraforaminal horizontal oblique osteotomy of the mandible.

PURPOSE: Today, the most common orthognathic procedure for correction of mandibular deformities is the bilateral sagittal split osteotomy, also called sagittal ramus osteotomy. Permanent injury to the mandibular nerve (V3) is one of the main complications, with a reported incidence between 5% and 30%. Orthognathic surgery using sagittal ramus osteotomy of the mandible as the procedure of choice should be re-evaluated because of the complexity and the relatively high risk of damage to the inferior alveolar nerve. Surgical techniques that allow for accurate condylar positioning with a lower risk of inferior alveolar nerve injury should be considered. The aim of this study is to present a retrospective case series using the previously described horizontal osteotomy of the mandibular rami along with modern-day technical advances that make this procedure safe, reliable, and reproducible. MATERIALS AND METHODS: We performed a modified approach to the supraforaminal horizontal oblique osteotomy of the mandible with a condylar positioning device, endoscopy, and a surgical navigation system. This technique was performed in 17 consecutive patients. Postoperatively, we measured the amount of surgical movement of the mandible, monitored the mandibular nerve, and evaluated bone healing during removal of the osteosynthesis plates. RESULTS: In all 17 treated patients there was uneventful wound healing, and no patient had permanent nerve alteration. The mean movement of the mandible was 7.48 mm (SD, 2.1 mm), with a range from 3.0 to 10.5 mm. The mean follow-up was 19 months. The main purpose of the surgical navigation was the translation of the planned osteotomy line from the computed tomography scan to the surgical site during the operation. This was performed to prevent a large gap between the bone segments at the osteotomy site. CONCLUSION: The supraforaminal approach with a condylar positioning device appears to be an appropriate way to prevent injury to the inferior alveolar nerve during orthognathic surgery of the mandible while maintaining centric positioning of the condyle and obtaining good bony union.

Bone grafting the mandible.

Many bone grafting techniques have been used to reconstruct the partially dentate and edentulous mandible. This article discusses the various bone grafting techniques to reconstruct mandibular defects. Also included are issues such as whether autogenous bone is necessary for reconstruction of the mandibular ridge and the importance of membranes.

Bone grafting the mandible.

Many bone grafting techniques have been used to reconstruct the partially dentate and edentulous mandible. This article discusses the various bone grafting techniques to reconstruct mandibular defects. Also included are issues such as whether autogenous bone is necessary for reconstruction of the mandibular ridge and the importance of membranes.