Lymphoepithelial carcinoma--review of the treatment modalities and report of a rare case in the sublingual gland.

Controversies exist in the current literature regarding the treatment of lymphoepithelial carcinoma (LEC). The presented study summaries the literature controversies in the treatment of LEC and present a case of a rare LEC diagnosed in the sublingual gland of an otherwise healthy 21-year-old Arab woman. The patient was admitted for swelling in the sublingual area. A biopsy indicated a diagnosis of LEC of the sublingual gland. Treatment included a wide resection with safe margins, marginal mandibulectomy, functional neck dissection, and a radial forearm free flap for reconstruction. The patient received concomitant radiotherapy and has remained disease free since her last follow-up. The recommended primary treatment, based on the literature review, is primary surgical excision with neck dissection and optional adjuvant radiotherapy to the gland area. Chemotherapy was not found to be beneficial according to the literature.

Combined treatment of aggressive central giant cell granuloma in the lower jaw.

BACKGROUND: The aggressive type lesions of central giant cell granuloma (CGCG) require wide resection that leads to major defects in the jaws. This form of surgical treatment can be particularly disfiguring. A number of alternative non-surgical therapies have been advocated in recent years for the management of the central giant cell granuloma (CGCG). These include calcitonin injections and nasal spray, intralesional steroid injections and subcutaneous interferon injections. MATERIALS AND METHODS: A large central giant cell granuloma aggressive type lesion in the mandible of a 24-year-old patient was treated successfully by intralesional injection of corticosteroid and nasal spray calcitonin that was followed by curettage with peripheral ostectomy with preservation of the continuity of the mandible and the teeth. At the 5-year clinical and radiological follow up there was no sign of recurrence. CONCLUSIONS: This combined medical and surgical treatment is advantageous for large aggressive lesions in order to reduce the size of the lesion and thus minimize the need for extensive bone resection and loss of teeth that can result in functional and aesthetic defects.

Treatment protocol for high velocity/high energy gunshot injuries to the face.

Major causes of facial combat injuries include blasts, high-velocity/high-energy missiles, and low-velocity missiles. High-velocity bullets fired from assault rifles encompass special ballistic properties, creating a transient cavitation space with a small entrance wound and a much larger exit wound. There is no dispute regarding the fact that primary emergency treatment of ballistic injuries to the face commences in accordance with the current advanced trauma life support (ATLS) recommendations; the main areas in which disputes do exist concern the question of the timing, sequence, and modes of surgical treatment. The aim of the present study is to present the treatment outcome of high-velocity/high-energy gunshot injuries to the face, using a protocol based on the experience of a single level I trauma center. A group of 23 injured combat soldiers who sustained bullet and shrapnel injuries to the maxillofacial region during a 3-week regional military conflict were evaluated in this study. Nine patients met the inclusion criteria (high-velocity/high-energy injuries) and were included in the study. According to our protocol, upon arrival patients underwent endotracheal intubation and were hemodynamically stabilized in the shock-trauma unit and underwent total-body computed tomography with 3-D reconstruction of the head and neck and computed tomography angiography. All patients underwent maxillofacial surgery upon the day of arrival according to the protocol we present. In view of our treatment outcomes, results, and low complication rates, we conclude that strict adherence to a well-founded and structured treatment protocol based on clinical experience is mandatory in providing efficient, appropriate, and successful treatment to a relatively large group of patients who sustain various degrees of maxillofacial injuries during a short period of time.

P27/SKP-2 histochemical profile is relevant to malignant salivary gland tumors (MST) histogenesis and tumor grade.

Malignant salivary gland tumors (MST) represent over more than 24 distinct morphological subtypes. Most high grade tumors arise from the excretory duct portion of the salivary gland apparatus; the remainder from the intercalated duct portion. Altered p27/skp-2 expression has been associated with tumor aggressiveness and histologic differentiation. In our study, we analyzed p27/skp-2 expression proteins on series of malignant salivary gland tumors in order to assess their value as a histogenetic marker, which is relevant to tumor grade. 61 MST cases were segregated by proposed histogenesis and immunohistochemistry was performed using antibodies directed against p27 and skp-2. MST of proposed intercalated duct origin (n=27) showed strong p27 expression (n=25/27; 93%) in the vast majority of cases and all cases weakly expressed skp-2. MST of proposed excretory duct origin (n=32) showed strong p27 expression (n=18/32; 56%) and moderately strong/strong skp-2 expression (n=18/32; 56%), respectively, in over half the cases. MST of intercalated duct origin showed evident p27/skp-2 inverse correlation. Differences in p27/skp-2 expression among the MST subtypes correlated with histogenesis and tumor grade, which reinforces the notion that tumor behavior is relevant to the portion of the salivary gland unit from which they arise. MST of proposed intercalated duct origin strongly expressed p27, and not skp-2, unlike MST of proposed excretory duct origin. The immunohistochemical profile of high grade mucoepidermoid carcinoma was distinct from its low/intermediate grade counterparts, suggesting a separate identity. These results may influence future decision making when formulating workable MST categorization schemes. Further studies on a larger series of MST are warranted in order to support the value of our findings.

Incidence of oral cancer occult metastasis and survival of T1-T2N0 oral cancer patients.

PURPOSE: In head and neck cancer, the most important prognostic factor is the presence or absence of neck metastasis. Although still debated in the published data regarding the "wait and see" policy for Stage T1-T2 oral cancer, a large number of clinicians support the necessity of neck dissection, especially in cases of oral tongue carcinoma, because of the poor prognosis and high risk of recurrence. The aim of the present study was to summarize and quantify the incidence of occult metastasis in oral cancer treatment at the oral and maxillofacial surgery department, Rambam Medical Center, in the past 10 years. PATIENTS AND METHODS: A total of 142 neck dissections performed at our department in the past 10 years (1998 to 2009) and a series of 68 patients (44 men and 22 women) treated for Stage T1N0 or T2N0 oral cancer were included in the present retrospective study. All patients underwent surgical resection of the oral cancer and selective neck dissection of the ipsilateral side. RESULTS: Occult lymph node metastases were detected in 11 patients (16% overall, 9 in the tongue, 1 in the buccal mucosa, and 1 in the gingiva of the mandible). The frequency of occult metastasis from tongue carcinoma was 34% (9 of 26 cases). The 5-year survival rate in the present study was 78.9%. In patients who underwent chemotherapy, radiotherapy, brachytherapy, or a combination of the 3 after surgical management, the overall survival rate decreased significantly to 22.5% (P = .006, log-rank test). CONCLUSION: The incidence of occult metastasis in patients with oral cancer in the present study was 16% overall. In those with tongue carcinoma, a much greater incidence (34%) of occult metastasis was detected. Furthermore, the need for chemoradiotherapy after initial surgical management, mainly because of occult metastasis, was a significant negative predictor of patient outcome. The results of the present study emphasize the need for prophylactic neck dissection in patients with oral cancer diagnosed with Stage T1N0 or T2N0 disease, especially when the primary lesion is localized in the tongue.

Polymorphous low grade adenocarcinoma: case series and review of surgical management.

PURPOSE: The aim of the present study was to review the published data regarding the management of polymorphous low-grade adenocarcinoma (PLGA) and present our experience in the treatment of patients diagnosed with PLGA. MATERIALS AND METHODS: We performed a review of the published data of the treatment possibilities for PLGA, and report on a case series of 4 patients diagnosed with palatal PLGA. RESULTS: The mean age at diagnosis was 61.75 years. All cases were localized on the hard palate. The male/female ratio was 1:3. One patient had an ulcerative painful lump. In correlation with the published data, most of our patients presented initially with a diagnosis that was not conclusive for the presence of PLGA. The most common initial diagnostic findings were adenoid cystic carcinoma and pleomorphic adenoma. The treatment of choice was surgical excision of the tumor with safe margins of 1.5 cm. One patient had a positive cervical lymph node metastasis and underwent an elective neck dissection followed by radiotherapy. Local recurrence was diagnosed in 1 patient 6 years after the surgical management. Most cases were reconstructed using an obturator, except for 1 patient who underwent reconstruction using the temporalis myofascial flap. CONCLUSIONS: PLGA is a slow-growing, distinct, uncommon neoplasm of the minor salivary glands. Because it is characterized by a diverse morphologic pattern that resembles adenoid cystic carcinoma or pleomorphic adenoma, the initial diagnosis is usually inconclusive. Until a final diagnosis has been made, we believe that the reconstruction possibilities should be mainly obturators to allow a good visualization of the surgical site. The use of microvascular free flaps or rotational flaps should be reserved to patients with clearer pathologic diagnosis.

Prognostic value of heparanase expression and cellular localization in oral cancer.

BACKGROUND: Metastases formation depends on the ability of tumor cells to invade basement membranes in a process involving enzymes capable of degrading extracellular matrix components. METHODS: We examined the expression of heparanase in oral carcinomas and correlated its staining extent, intensity, and cellular localization with patients' outcome. RESULTS: Quantitative real-time polymerase chain reaction (PCR) revealed over 4-fold increase in heparanase levels in oral carcinomas compared to adjacent normal tissue. Normal oral epithelium was found negative for heparanase, while all oral carcinomas stained positively for heparanase. Heparanase staining was associated with Ki67 staining, a measure of cell proliferation. Notably, whereas cytoplasmic localization of heparanase was associated with high-grade carcinomas, nuclear localization of the enzyme was found primarily in low-grade, well-differentiated tumors, and in all oral verrucous carcinomas. CONCLUSION: Expression level and cellular localization of heparanase could serve as an important diagnostic marker in patients with oral cancer.

Superficial parotidectomy versus retrograde partial superficial parotidectomy in treating benign salivary gland tumor (pleomorphic adenoma).

PURPOSE: Of all benign salivary gland tumors of the parotid gland, pleomorphic adenoma (mixed tumor) is the most common. It accounts for 60% to 70% of all benign tumors of the parotid gland. This neoplasm arises in patients in the fourth to sixth decade of life, with a female predominance. The surgical excision of this lesion continues to be the subject of major debate. The goal is to avoid facial disability yet attain complete resection without perforation of the capsule/pseudocapsule. The purpose of our study is to compare 2 surgical techniques performed at the Ear, Nose, and Throat and Maxillofacial Departments, Rambam Medical Center, Haifa, Israel, and determine which is preferable in treating this lesion. PATIENTS AND METHODS: We reviewed 48 patients who underwent excision of pleomorphic adenoma of the parotid gland between 1996 and 2005 at Rambam Medical Center: 18 were treated surgically with the classical superficial parotidectomy (SP) technique, using an anterograde approach, and 30 were treated with retrograde partial superficial parotidectomy (PSP). We compared the 2 surgical techniques in terms of surgical time, histopathologic size of the lesion, amount of excised healthy parotid tissue, histologic margin, and the preservation of the capsule/pseudocapsule. We also made clinical records of temporary or definitive injury to the facial nerve, which branches of the facial nerve were temporarily or definitively injured, the occurrence of Frey syndrome, esthetic satisfaction, and the amount of recurrence or infection after surgery. RESULTS: Of the 48 patients, 19 (39.6%) were male and 29 (60.4%) were female, with a mean age (+/- SD) of 43.8 +/- 16.97 years (median, 50 years; range, 12-79 years). We found a significant difference (P = .029) in mean surgical time (+/- SD): 171 +/- 49.7 minutes (median, 165 minutes) when performing the classical SP and 145 +/- 42.7 minutes (median, 130 minutes) when performing the retrograde PSP. Much more healthy parotid tissue was taken out with the classical procedure (mean, 51.4 +/- 13.6 mm; median, 50 mm) than with the retrograde PSP technique (mean, 39.2 +/- 11.8; median, 35 mm) (P = .01). There was a significant difference (P = .0003) in facial nerve injuries: 39% of patients did not report any facial deficit in the SP group compared with 90% in the PSP group. In the SP group, only 3 patients reported a permanent deficit, and in the PSP group, only 3 patients had a temporary deficit (compared with 8 in the SP group). The main injuries occurred in the mandibular branch with both techniques: 6 SP and 2 PSP. There was no difference in esthetic satisfaction: 72.2% of patients in the SP group and 80% in the PSP group had no esthetic complaints. In the SP group, patients mainly complained about swelling (3 patients), and in the retrograde PSP group, the main complaint was depression (4 patients). Frey syndrome was found in 9 patients in the retrograde PSP group and 4 in the classical SP group (with an overall rate of 27.7%). The lesion recurred in only 2 patients--1 in each group. CONCLUSION: With both of the techniques, we found satisfactory results. In the majority of cases, retrograde PSP is a superior technique to the classical SP, although Frey syndrome is more often observed with the former.

Novel ultrasonic device to measure the distance from the bottom of the osteotome to various anatomic landmarks.

BACKGROUND: The aim of the present study is to intraoperatively measure the distance from the bottom of the osteotome to the inferior alveolar canal (IAC) and maxillary sinus floor using a novel ultrasonic device and to compare the measurements to those using conventional radiographs. METHODS: Patients scheduled for dental implant placement in the posterior regions were recruited for this pilot study. Mucoperiosteal flaps were elevated, and a recipient site was initiated using a standardized 2-mm-diameter pilot drill. The distance from the bottom of the osteotome to the IAC and maxillary sinus floor was assessed using a newly developed ultrasonic device and compared to a standard panoramic radiograph that was used to measure the same residual distance from the bottom of the drill. RESULTS: Fourteen consecutive patients (21 implants) were enrolled. Eleven implants were placed in posterior mandibles, and 10 implants were placed in posterior maxillae. The mean +/- SE radiographic distance from the apex of the pilot drill to the nearest cortical bone was 5.64 +/- 0.51 mm, which was very similar to the distance measured by the ultrasonic device (5.22 +/- 0.37 mm; P = 0.341). In posterior mandibles (n = 11), the distances were 5.18 +/-0.61 mm (radiographic) and 5.26 +/- 0.61 mm (ultrasonic), which were not statistically significant (P = 0.593). A very strong positive correlation was observed between the two measurements in mandibles (r = 0.967; P = 0.0001). CONCLUSION: The results of this in vivo study support the value of this ultrasonic system in measuring the residual osseous depth from the bottom of the osteotome to the roof of the IAC.

Chronic obstructive parotitis due to strictures of Stenson's duct--our treatment experience with sialoendoscopy.

PURPOSE: The present retrospective analysis was performed to assess the effectiveness of sialoendoscopic treatment of chronic obstructive parotitis. MATERIALS AND METHODS: The study group included 87 parotid glands with stricture as the only cause of gland obstruction. After sialographic and sialoendoscopic evaluation, sialoendoscopic 4-step surgical treatments were performed. The treatment protocol was designed. RESULTS: Sialoendoscopy proved to be a successful procedure in 94.7% of the affected parotid glands we treated. CONCLUSION: The minimally invasive technique of sialoendoscopy for treatment of strictures of the salivary glands could be a welcome innovation, helping to avoid radical surgical treatment of salivary gland disease.

Surgical approach to impacted mandibular third molars--operative classification.

PURPOSE: The aim of the present study is to suggest a convenient way to classify the position of the impacted third mandibular molar relative to the mandibular canal and to suggest indications for the use of each surgical approach for mandibular third molar extraction. MATERIALS AND METHODS: The presented new typing system, Third Molar Classification (TMC), is a simple and easy-to-apply method for the surgical management of mandibular third molars and can be extended for any ectopic or impacted mandibular tooth. There are 3 major types of third molar positions. The second type is subdivided further into 2 subtypes. In the present study, 9 patients with high-risk mandibular third molars were treated according to the present classification and are presented and discussed. Patients typed as TMC IIb were treated with a sagittal split osteotomy approach and patients typed as TMC III were treated with an extraoral approach. RESULTS: The operative classification was successfully implemented in very rare cases of deeply impacted mandibular third molars. In 3 of 9 cases (33%) minor complications included some degree of hypoesthesia using the extraoral approach; these complications resolved spontaneously without the need for any intervention. CONCLUSIONS: The present study describes the use of a new surgical classification system for treatment planning in all types of mandibular third molar extractions. We believe that the present classification could help the oral and maxillofacial surgeon in decision-making and limit the possible risks that are present when attempting to extract impacted mandibular third molars.

The use of the temporalis myofascial flap in oral cancer patients.

PURPOSE: The purpose of this article is to present our experience using the simple, reliable, and predictable temporalis myofascial flap (TMF) in rehabilitation and reconstructive surgery in cancer patients who are older and whose health is compromised in a way that precludes the use of microvascular free flaps. PATIENTS AND METHODS: Our series includes 10 patients (8 men and 2 women), ranging in age from 62 to 85 years (mean, 73.4 years). A full-thickness anteroinferiorly based TMF was used in 5 patients for palatal reconstruction, 3 patients for buccal lining reconstruction, and 2 patients for reconstruction after resection of facial skin and buccal mucosa. RESULTS: The TMF survival rate in this study was excellent, with an 80% success rate (2 minor complications). Complications included 1 case of a partial distally necrotic flap that resolved after local debridement and did not require further flap manipulation and 1 case of transient, spontaneously resolved facial nerve (temporal branch) palsy and limited mouth opening (<20 mm), which also resolved after judicious physiotherapy. CONCLUSIONS: The TMF was found in this study to have a fairly low complication rate, was relatively easy to use, and had a predictable outcome. The proximity and reliability of the myofascial flap make it a favorable and highly recommended candidate for oral and maxillofacial reconstructive surgery in elderly patients, who usually have relatively poor recovery potential and decreased physiologic reserves.

Malignant salivary gland tumors and cyclo-oxygenase-2: a histopathological and immunohistochemical analysis with implications on histogenesis.

The classification system for malignant salivary gland tumors (MST) is largely dependent on its histogenesis. The histogenesis is uncertain but the "bicellular theory of origin" has been accepted by most and states that malignant transformation of reserve cells from either the intercalated or excretory duct are responsible for the development of MST. Cyclooxygenase-2 (cox-2), a potential molecular marker for MST, was analyzed on a series (n=56) of MST with the aim of determining the morphological MST subtypes capable of cox-2 overexpression and correlating its expression with histogenesis. Fifty six primary major and minor gland MST were stained with anti-cox-2 antibody and rated with a combined score that added a scale of intensity to the percentage of tumor cells that overexpressed the cox-2 protein. A score of <3: negligible or negative staining; score of 4-5; moderate staining; score of 6-7; strong staining. Tumor types were segregated by morphology, histological features and proposed histogenesis. Strong cox-2 overexpression was noted in all MST of proposed excretory duct origin: salivary duct carcinoma (100%), mucoepidermoid carcinoma (MEC) (92%), and adenocarcinoma nos (AdC nos) (83%). Primary squamous cell carcinoma (PSCC) was the exception. Negative expression was noted in all tumors of proposed intercalated duct origin (adenoid cystic carcinoma, basal cell adenocarcinoma and acinic cell carcinoma) with the exception of one case of polymorphous low grade adenocarcinoma. Strong cox-2 overexpression was noted in the epidermoid cells of MEC, abluminal duct cells surrounding the duct-like structures and ductal cells of AdC nos and salivary duct carcinoma. Myoepithelial and acinar cells were unreactive. Although preliminary, the results of our study support the concept that MST of proposed excretory duct origin share a common histogenesis. Negligible cox-2 expression in PSCC may provide a useful tool for diagnosing the often histologically indistinguishable cases of high grade MEC. Follow-up studies on a larger series of MST are warranted.

Odontogenic myxoma--a case series and review of the surgical management.

BACKGROUND: Odontogenic myxomas (OMs) are considered to be a benign odontogenic tumour with locally aggressive behaviour. Since these neoplasms are rare in the oral cavity, the possible surgical management can be quite variable. Literature recommendation can vary from simple curettage and peripheral ostectomy up to segmental resection. CASE REPORTS: In the present article, a series of three new cases are presented and discussed. The first case is a 43-year-old male presented with a relatively large OM in the left maxillary area. The second case is a 37-year-old female presented with a relatively smaller left maxillary swelling that was diagnosed as OM. The third and final case is a 52-year-old male presented with a large OM of the right mandibular molar area. The surgical management that was chosen in each case is discussed. CONCLUSION: In the present manuscript, a short review of the current literature on the surgical management of OMs is presented with a review of three cases of oral OMs that were treated in our department, followed by a discussion of the treatment options in each case.

Immediate and delayed restoration of dental implants in periodontally susceptible patients: 1-year results.

PURPOSE: Immediate restoration of dental implants in patients with a history of periodontal disease was examined. The influence of insertion torque and implant stability quotient (ISQ) on the survival rate was compared in immediately restored, nonrestored, and submerged implants. MATERIALS AND METHODS: Patients received periodontal treatment after which "all in one" implant surgery was performed: hopeless teeth were extracted, debridement around remaining adjacent teeth was performed, implants were inserted and, in some cases, a prefabricated screw-retained provisional restoration was immediately delivered. Insertion torque and ISQ were recorded at baseline and 6 and 12 months postsurgery. RESULTS: Nineteen patients were treated, and 74 implants were placed. Twelve implants, 10 of which were maxillary, failed in 4 patients. Survival rates were 100% in partial-arch restorations, 94% in the mandible, and 78% in the maxilla. The survival rate of restored implants was 65% in extraction sites versus 94% in healed, nonextraction sites. Implants exhibited a decrease in ISQ at 6 months followed by an increase at 12 months. There were no statistically significant differences in insertion torque or ISQ between failed and successful implants, restored and nonrestored implants, or extraction-site and nonextraction-site implants. Mandibular implants demonstrated higher insertion torque and higher ISQ at baseline and 6 and 12 months. CONCLUSIONS: Within the limits of this study, immediate restoration of dental implants in periodontally susceptible patients had a variable success rate. Several factors were shown to affect these results.

Dento-alveolar and maxillofacial injuries - a survey of knowledge of the regimental aid providers in the Israeli army.

The present study evaluated the knowledge of physicians and emergency medical technicians (EMT) regarding primary treatment for oral and maxillofacial trauma and assessed the experience they have in treating oral and maxillofacial injuries. The study population consisted of 80 military physicians and EMT during their military service. A questionnaire was distributed relating to demographic data such as age, gender, position, and type of military service, as well as past experience in treating or witnessing oral and maxillofacial trauma, former education regarding diagnosis and treatment of oral and maxillofacial trauma, assessment of knowledge regarding oral and maxillofacial trauma, etc. The questionnaire was answered by 76 participants (95% response rate): 32 physicians and 44 EMT. Only 17 (22.4%) received education regarding oral and maxillofacial trauma (eight physicians, 25% and nine EMT, 20.5%). Nevertheless, 23 (30.3%) reported witnessing such an injury during their military service. Oral and maxillofacial injuries were first seen by the EMT in 43.4% of the cases, a physician in 23.7%, and a dentist in only 9.2%. Overall, 66 (86.8%) of the physicians and EMT stated that it was important to educate the primary health care providers regarding diagnosis and treatment of oral and maxillofacial trauma. Special emphasis should be given to providing primary caregivers with the relevant education to improve their knowledge and ability of dealing with diagnosis and treatment of oral and maxillofacial trauma.