Surgical challenges in the treatment of advanced cases of ameloblastoma in the developing world: The authors' experience.

Total mandibulectomy was carried out in 32 patients with extensive oro-facial lesions histologically diagnosed as ameloblastoma in four specialist centres in south-eastern Nigeria from January 2001 to December 2006. All the patients presented at an advanced stage with the whole mandible affected so the treatment of choice was total mandibulectomy. The patients gave informed consent for surgery. The standard surgical procedure was the same in all cases and was performed by the same surgeons. Of the 32 mandibles removed, there were 13 male (41%) and 19 female (59%) patients, giving a male-to-female ratio of 1:1.6. Three (9%) patients died due to problems relating to anaesthesia while five (16%) had postsurgical-related psychosomatic problems. Generally, the postoperative recovery was characterized by reduction in the quality of life of these patients because immediate jaw reconstruction was not feasible. This article highlights the challenges in the surgical management of advanced cases of ameloblastoma in the developing world and proposes a middle ground for professional interactions and exchange programmes among oral and maxillofacial surgeons across the world to assist poorer countries in the management of these advanced cases of oro-facial tumours.

A technique of tongue fixation after total mandibulectomy: the Oji spatula.

When ameloblastoma presents late, as is often the case in Nigeria, it can affect the whole mandible. The treatment of choice is total mandibulectomy. The procedure may necessitate the resection of the musculature of the floor of the mouth to which a large portion of the tongue is attached. In our hospitals, immediate reconstruction is not undertaken for various reasons. Consequently, the musculature of the floor of the mouth cannot be reattached to a graft. The purpose of this paper is to illustrate a simple and patient-friendly method for fixation of the tongue after total mandibulectomy to achieve a secure airway. The tongue is tied to a wooden spatula, which stretches horizontally across the mouth. It is in contrast to the conventional technique of rigid fixation of the tongue to the pectoral muscle. This technique was used for 11 patients with large ameloblastomas. For the purpose of comparison, the conventional technique was used in 4 patients. The method of using a wooden spatula as a means of tongue fixation is known in the maxillofacial unit of the University of Nigeria Teaching Hospital, Enugu as the Oji spatula after the surgeon who developed it. All 11 patients tolerated this method well, but the 4 patients who had their tongues tied to the pectoral muscle complained of pain and discomfort. All the patients survived the procedure without postoperative blockage of the airway by the tongue. Follow-up for up to 6 months established that the patients had no respiratory problems.

Impacted mandibular third molars: depth of impaction and surgical methods of extraction among Nigerians.

This study was conducted in three centres. 717 impacted mandibular third molars were extracted from 517 patients. 69.1% of the extractions were in patients aged 25 years and below. A total of 96.1% extractions were done under local anaesthesia while 3.9% were under general anaesthesia. The lingual bone split technique was used in 2.5% extractions while the bur was used in 97.5% extraction. The patient's preference, the number of teeth to be extracted, and the depth of impaction were the main predicators in the choice of anaesthesia. Majority of third molars with a depth of 5 mm or more were extracted under local anaesthesia. Paraesthesia of the inferior dental nerve and alveolar osteitis were more frequent when extractions were done using the bur technique under local anaesthesia, while paraesthesia of the lingual nerve was more when extractions were performed using the lingual bone split technique under general anaesthesia.

Evaluation of precautions adopted by dental surgeon using local anaesthesia.

There were 62 surgeons consisting of 38 (61.3%) males and 24 (38.7%) were females. Thirty-one (50%) were from private and state government owned clinics while the rest were from teaching hospitals. Thirty-three (53.2%) were dental house surgeons, senior dental house surgeons and dental officers, while 29 (46.8%) were within the rank of registrar and senior dental officer, senior registrar, principal dental officer and consultant. Six (9.7%) use aspirating syringe all the time. 11 (17.7%) use aspirating syringe occasionally and 45 (72.6%) use non aspirating syringe. All the surgeons wear facemasks and latex gloves. On the replacement of the needle guard after injection, 58 (93.5%) indicated that the needle is first inserted into the needle guard and then secure 4 while 4 (6.5%) pick-up the guard with their fingers, place it over the needle and secure the guard. Eight (12.9%) indicated that the maximum dose of 2% lignocaine with adrenaline 1:80,000 is 7 mg/kg body weight or less, 5 (8.1%) indicated 10 mg/kg body weight, while 49 (79.0%) did not complete this section. On the maximum number of 1.8 ml cartridges, all the surgeons indicated that the maximum is 12 or fewer cartridges. This study revealed that the risk of intravascular injection is high. Although of the most dental surgeons take necessary precautions to avoid complications arising from the use of local anaesthetics, there is a need for total compliance in view of fatal complications that may ensue. It also underscores the need for continuous dental education program to update practitioners.

Effects of vitamin A supplementation during pregnancy and early lactation on body weight of South African HIV-infected women.

Effects of vitamin A supplementation during pregnancy and early lactation on maternal weight among HIV-1-seropositive South African women were examined. Three hundred twelve HIV-seropositive pregnant women between 28 and 32 weeks gestation were studied as part of a randomized, double-blind, placebo-controlled trial at the King Edward VIII Hospital in Durban, South Africa. Patients were randomized to receive placebo or 5,000 IU of retinyl palmitate and 30 mg of beta-carotene daily during pregnancy. At delivery, patients received placebo or 200,000 IU of retinyl palmitate. The main outcome measures were prenatal and postnatal maternal weight and weight loss at three months after delivery as measured in body mass index (BMI). Supplementation of vitamin A was not associated with improvements in prepartum weight gain but was significantly associated with improved weight retention three to six months after delivery (p = 0.02). The benefit of vitamin A supplementation appeared to be confined to subgroups with baseline CD4+ count < 200 cells/microL and serum retinol 0-20 micrograms/dL. Similar trends were observed in maintenance of postpartum BMI. However, no statistically significant associations were observed. Although there was no benefit of vitamin A supplementation on prepartum weight gain, a benefit on maintenance of postnatal weight was observed. The benefit was highest among those who were vitamin A-deficient or whose CD4+ count was < 200 cells/microL presupplementation. In populations for whom antiretroviral therapy is not readily available or accessible, the finding that vitamin A may improve postpartum weight lends some hope to a relatively inexpensive treatment which could be used for helping ameliorate some weight loss which is common during HIV infection.

[Burkitt lymphoma. Study of 110 patients]. / Burkitt-Lymphom. Studie über 110 Patienten.

A review of 110 children with Burkitt's lymphoma admitted to the University of Nigeria Teaching Hospital, Enugu during a 7-year period revealed a preponderance of males over females (1.9:1) and a peak incidence at five years. The main sites affected initially by the tumour in order of frequency were the face and abdomen. The spinal column, spleen, and lungs were less affected. It is postulated that an interaction between malarial and Epstein-Barr virus infections and malnutrition are important in the aetiology of the tumour. The most effective drug is cyclophosphamide. A combination of this drug with vincristine and methotrexate is equally effective in inducing remissions, but is better than the single agent in preventing systemic relapse. Follow-up of the patients revealed good survival.

Jaw fractures in Enugu, Nigeria, 1985-95.

A retrospective analysis of 900 patients with jaw fractures of the facial bones during the period January 1985 - December 1995 indicated that 747(83%) resulted from road traffic accidents, 75(8.4%) from interpersonal violence, 39(4.3%) from accidents during sporting events, and 36(4%) from occupational accidents, while the causes of 3(0.3%) were not stated. The left side of the face was affected more often than the right. The mandible was twice as likely to be fractured as the zygomaticomaxillary complex. The symphysis-body-angle and the condylar region were the most common sites of fracture of the mandible, while the zygoma was the area most often affected in the middle third of the face. Most maxillofacial fractures occurred in the age group 21-30 years, and the lowest among those over 60. Three times as many men were affected as women. We conclude that there is high incidence of fractures of the facial bones caused by traffic accidents in our environment and, in all age groups, men were more likely to be affected than women.

Late presentation of orofacial tumours.

One hundred and twenty-eight cases of tumours involving the oral and the maxillofacial region and the oropharynx were reviewed. The objective was to highlight the late presentation of orofacial tumours in Nigeria. Patients who presented with squamous cell carcinoma, ameloblastoma, Burkitt's lymphoma, fibrous dysplasia and pleomorphic adenoma between January 1993 and December 1997 were selected. The socio-economic class of each patient was noted. Ignorance and poverty were the main reasons for the late presentation of 120 patients who belonged to the lower social class. Four middle-class patients and four upper class ones gave marital problems and a sense of despair as reasons for the delay in seeking treatment. Difficulties in their management are attributed to the advanced stage of the tumours and the high rate of patients' default. There is the need to emphasize not only the necessity for early presentation but also the establishment of adequate facilities in this country, and other developing countries, for effective treatment of these tumours.

Statistical observations on jaw cysts in Enugu, Nigeria, 1987-1996.

Cases of jaw cysts treated at the Department of Oral and Maxillofacial Surgery in the University of Nigeria Teaching Hospital, Enugu during the 10 year period between 1987 and 1996 were studied clinically. A diagnosis of jaw cyst was established in 20 patients during the above period. According to pathological classification by the WHO method, these patients included 10 (50%) with dentigerous cyst, 3 (15%) with radicular cyst, 3 (15%) with odontogenic keratocyst, 3 (15%) with fissural cyst (nasopalatine duct cyst, nasoalveolar cyst, globulomaxillary cyst), 1 (5%) with dermoid cyst. Patients with dentigerous cyst, which was found at relatively high frequency, were further analyzed with regard to age, sex, and anatomical distribution. Among patients with dentigerous cyst, those aged between 21 and 40 years accounted for 60%. Males outnumbered females in a ratio of 1.5:1. Dentigerous cyst occurred most frequently in the region of the mandibular wisdom teeth. The relatively very small number of cases, the need for more research on the subject and the need to educate the general public on oral hygiene are highlighted.

Fractures of the facial skeleton in children: a survey of patients under the age of 11 years.

A clinico-statistical study was performed on 40 children aged less than 11 years of age, with maxillofacial fractures. Age, sex, type of fracture, incidence, aetiology, methods of treatment and complications were studied. The ratio of boys to girls was 2.6:1.0 and the highest incidence was at age 10 years. Mandibular fractures were the most common and the condylar region was particularly affected. Falls, road traffic accidents and sport injuries, including play accidents, were the major causes of these injuries. Conservative therapy, such as maxillo-mandibular fixation using eyelet wiring, was usually performed and was found to be successful. Ankylosis of the temporomandibular joint was seen in one patient. Infection was observed in three cases. One child had retarded facial growth due to damage to the condylar growth centre. Malunion and non-union were not seen. No deaths were recorded.

Diastema in Nigerian Society

The frequency of occurrence of diastema and its acceptability was studied. Diastema occurs more among females and Nigerians primarily regard diastema as a thong of beauty. Some even go to have it created for them artificially. Of the various forms; maxillary midline diastema is the most prevalent while mandibular midline is the least. There is preference for the midline anterior diastema and therapy to close the diastema was considered unnecessary. Lateral diastema is not as much favoured. There is also an indication that diastema runs in some families

Purification and properties of D-beta-hydroxybutyrate dehydrogenase from Zoogloea ramigera I-16-M.

D(-)-beta-Hydroxybutyrate dehydrogenase was purified from Zoogloea ramigera I-16-M to electrophoretic homogeneity. The molecular weight of the enzyme as determined by Sephadex G-200 gel filtration was 112,000, and the monomer molecular weight estimated by polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulfate was 28,000, indicating that the native enzyme is a tetramer with four identical subunits. The enzyme showed a pH optimum at 8.0 in the oxidation reaction, and a broad pH optimum (5.5-7.5) in the reduction reaction. The Km values for D(-)-beta-hydroxybutyrate and NAD in the oxidation reaction were 3.2 X 10(-4) M and 5.7 X 10(-5) M, respectively. The Km value for acetoacetate in the reduction reaction was 1.5 X 10(-4) M and that for NADH was 1.5 X 10(-5) M. Acetyl CoA, D-lactate, and 2-hydroxybutyrate were effective inhibitors for the oxidation of D(-)-beta-hydroxybutyrate. The enzyme was sensitive to the inhibitory actions of sulfhydryl reagents such as p-chloromercuribenzoic acid, 5,5'-dithiobis(2-nitrobenzoic acid) and HgCl2.