Update on Antimicrobial Therapy in Management of Acute Odontogenic Infection in Oral and Maxillofacial Surgery.

This article focuses on the antimicrobial therapy of head and neck infections from odontogenic origin. Odontogenic infections are among the most common infections of the oral cavity. They are sourced primarily from dental caries and periodontal disease (gingivitis and periodontitis). Many odontogenic infections are self-limiting and may drain spontaneously. However, these infections may drain into the anatomic spaces adjacent to the oral cavity and spread along the contiguous facial planes, leading to more serious infections. Antibiotics are an important aspect of care of the patient with an acute odontogenic infection. Antibiotics are not a substitute for definitive surgical management.

Immediate Implants.

Immediate implants have become a popular option for replacing teeth. This article describes the surgical and restorative considerations involved in the planning and placement of an immediate implant. Immediate implants require appropriate hard and soft tissue assessment. Virtual planning can help assist in planning of immediate implants. Radiographic and computed tomographic guidance can help in establishing the relationship between the planned implant to the hard tissue and anatomic structures. This article discusses a technique in fabrication of the immediate provisional and final restoration.

Theoretical Basis for Virtual Skull Orientation According to Three-Dimensional Frankfort Horizontal Plane for Computer-Aided Surgical Simulation.

PURPOSE: Computer-aided surgical simulation (CASS) is an evolving technology which has significantly affected surgical correction of dentofacial deformities, a key step of which is orientation of the virtual skull model to allow for analysis and treatment planning. Explored in this study is the coplanarity of a 3-dimensional Frankfort horizontal plane (3D FHP). MATERIALS AND METHODS: The 122 17.0 cm field-of-view cone-beam computed-tomogram (CBCT) scans were oriented to a 3D FHP using right porion, right orbitale, and left orbitale. The distance between the 3D FHP and left porion was then measured. The 18 CBCT scans were found to have external fiducial markers which were used for orientation into natural head position (NHP). The distance between left porion and a true horizontal plan coincidental with the right porion was measured. Concordance reliability measures were calculated to compare NHP to 3D FHP. RESULTS: The average distance of left porion to 3D FHP was found to be -0.107 mm (SD = 1.148), and the average distance from the coincidental left porion in NHP was found to be 0.846 mm (SD = 2.611). Concordance reliability calculations shows little consistency between the 2 methods of orientation (P = 0.838). CONCLUSIONS: The data shows coincidence between left porion and 3D FHP. Orientation of the virtual skull model according to 3D FHP offers a quick and easy method for this important step in CASS. Further study is needed for evaluation of this method in vivo.

Bifid Mandibular Canal: A Case Review and Retrospective Review of CBCTs.

PURPOSE: This case presentation and retrospective review of cone-beam computed tomograms is to evaluate prevalence, classification, and demographics of bifid mandibular canals (BMC) to inform practitioners on this variation and avoid untoward complications due to failure to diagnose. MATERIALS AND METHODS: Two thousand one hundred thirty scans were evaluated by 2 oral and maxillofacial radiologists. BMCs were noted and classified according to Naitoh. Demographic data were also collected and analyzed. RESULTS: Twenty-eight patients were noted to have bifid mandibular canal, with an average age of 39 years (± 19.5), with no strong sex predilection. Patients (1.31%) were noted to have bifid canals. A greater percentage of patients were shown to have bilateral bifid canals (42.9%) versus either unilateral side (25% left, 32.1% right), but is statistically insignificant. Prevalence was greatest in types 1 and 3 (35.9% and 51.3%, respectively, P = 0.000011). Types 2 and 4 were much less common. CONCLUSION: BMCs are an important anatomic variation that has implications on any mandibular surgery, including implant surgery. Just more than 1% of patients have this variation, but failure to recognize this in a patient can result in poor outcome, as illustrated in the case presented.

Hypotensive anesthesia: Comparing the effects of different drug combinations on mean arterial pressure, estimated blood loss, and surgery time in orthognathic surgery.

UNLABELLED: Sevoflurane, an inhalational hypotensive anesthetic agent with a vasodilatory property, has been commonly used as a single agent to induce hypotension and effectively decrease blood loss in orthognathic surgery. However, it is common for patients to receive other hypotensive anesthetic agents in combination with sevoflurane. The purpose of our retrospective cohort study is to investigate whether administering an additional hypotensive agent has greater effect at reducing mean arterial pressure (MAP), estimated blood loss (EBL) and surgery time during orthognathic surgery. MATERIAL AND METHODS: 57 subjects, aged 0-89 of both genders, who underwent orthognathic surgery were investigated in this study. Each patient's anesthesia records were reviewed to record the following variables of interest: EBL, duration of surgery, and MAP reduction in %. 41 subjects were placed in Group I and they received sevoflurane alone. 16 subjects were placed in Group II and they received sevoflurane plus a "supportive" agent. These "supportive" agents were esmolol, labetalol, metoprolol, nicardipine, and dexmedetomidine. The significant differences between two groups were assessed by using ANCOVA and p < 0.05 was regarded as significant. Wilcoxon signed-rank test was used to look for differences in surgery time. RESULTS: Subjects in Group II experienced a greater reduction in MAP during surgery than subjects in Group I, 27.30% and 20.44%, respectively (p = 0.027). There was no significant difference for sex (p = 0.417) or age group (p = 0.113) in estimated blood loss, however. The mean surgery time in Group I was 1.93, 2.77, and 4.54 h with respect to LeFort, BSSO/IVRO, and double jaw surgery. Patients in Group II had a mean surgery time of 1.73, 2.07, and 5.64 h with respect to LeFort, BSSO/IVRO, and double jaw surgery. No statistically significant difference was demonstrated in surgery time between Group I vs. Group II (p > 0.05). Subjects in Group II experienced, on average, more blood loss than subjects in Group I, 355.50 ml and 238.90 ml, respectively. CONCLUSION: The use of multi-drug combination may offer significant advantage of reducing patients' mean arterial pressure. However, this has no significant effect on reducing blood loss or surgery time in comparison to sevoflurane alone.

Pediatric Maxillofacial Trauma: A Review of 156 Patients.

PURPOSE: To review the epidemiology and management of facial fractures in a pediatric population. MATERIALS AND METHODS: This study was a retrospective review of patients younger than 18 years who presented to a pediatric emergency department during a 5-year period in an urban, academic, level 1 designated trauma center. RESULTS: Of the 156 patients identified, most were boys (87%) and the mean age was 13.5 years (standard deviation, 4.9 yr; interquartile range, 12 to 17 yr). The most common mechanism of injury was assault (48.1%). Mandibular fractures (40.7%) were most common. Multiple fractures occurred in 26.9% of patients. Concomitant injuries occurred in 73.7% of patients, most commonly concussions (39.1%). Intracranial hemorrhages were associated with panfacial (P = .005), frontal (P = .001), and orbital (P = .04) fractures. Most patients (91.7%) were admitted, and nonoperative repair was undertaken in 57.1%. There was an independent association of surgical intervention with age older than 14 years and with mandibular fractures (P < .01). CONCLUSIONS: Assault was the most common mechanism of injury and mandibular fracture was the most commonly encountered. Concomitant nonfacial injuries occurred in most patients. Patients sustaining panfacial, frontal, and orbital fractures should provoke an evaluation for other intracranial injuries. Children older than 14 years and those with mandibular fractures should prompt mobilization of resources for operative repair.

Dental treatment of the pregnant patient: literature review and guidelines for the practicing clinician.

The purpose of this review article is to assist the practicing clinician by categorizing and packaging useful clinical information into a format that will assist with the treatment of pregnant patients. Our goal is to offer the scientific foundations that lead to current practice guidelines, specifically those that are of particular relevance to today's dental professional.

Use of temporary anchorage devices in regaining lost interocclusal space. Case series.

The absence of interocclusal space, a common consequence of trauma, maxillofacial pathology or carious process, causes loss of function, compromised aesthetics for the patient, and represents a major challenge for the restorative dentist. Such cases were treated historically with dental procedures and orthodontic appliances, which, in turn, caused associated unwanted sequelae. The introduction of mini-implants for skeletal anchorage presents a change in treatment paradigm and provides a safe and successful management of the absent space without undesirable side effects. We present three cases of a successful adjustment of vertical correction with temporary skeletal anchorage from mini-implants.

Tonsilloliths appearing as multiple opacities on panoramic imaging: case report.

Tonsilloliths are dystrophic calcifications that can form in tonsillar crypts. They can be asymptomatic or a component of tonsillitis. This article presents a case of tonsilloliths that appeared on a panoramic image as multiple opacities.

Analysis of skeletal mandibular abnormalities associated with cervicofacial lymphatic malformations.

OBJECTIVES/HYPOTHESIS: Many children with cervicofacial lymphatic malformations have facial skeletal abnormalities. This study qualitatively and quantitatively evaluated these bony mandibular abnormalities. STUDY DESIGN: Retrospective chart review. METHODS: Patients with craniofacial lymphatic malformations presenting to a vascular anomalies center during a 2-year period were included. An age-matched control population was found on the Picture Archiving and Communication System database. Three-dimensional reconstructions were created from computed tomography and magnetic resonance imaging. Qualitative observations and quantitative measurements were taken of the gonial angle, mandibular anterior dentoalveolar height, and anterior condylar displacement. RESULTS: There were 23 controls. A total of 21 patients with "beard" distribution malformations were studied; 10 had unilateral and 11 had bilateral disease.Qualitatively, a few patterns emerged: outward ramal flaring, anterior displacement of the mandible, relative ipsilateral facial "hypertrophy," and anterior positioning of the maxilla and orbit. The open-bite deformity was a common finding leading to malocclusion and oral incompetence. Quantitatively, in 67 nondiseased sides, the average gonial angle was 131 degrees (standard deviation [SD] = 6.8), whereas in 32 diseased sides, the average angle was 152 degrees (SD = 14.0, P < 3.8E-09). With half-beard malformations, the diseased side averaged 153.9 and the nondiseased side averaged 140.8 (P = .008). The average condylar displacement was 8.5 mm versus 5.9 mm (diseased vs. nondiseased), and the average mandibular dentoalveolar height to face ratio was 0.37 (control = 0.34). CONCLUSIONS: Cervicofacial lymphatic malformations in the "beard" distribution are associated with significant bony abnormalities leading to both functional and aesthetic sequelae. Our study is the first quantitative analysis of these changes. This is the first step in planning for dentofacial orthopedics, orthodontics, and orthognathic surgery.

Skeletal facial balance and harmony in the cleft patient: Principles and techniques in orthognathic surgery.

The management of the palatal cleft, dental arch, and subsequent maxillary form is a challenge for the craniomaxillofacial surgeon. The purpose of this paper is to present the experience of a senior surgeon (KES) who has treated over 2000 patients with cleft lip and palate. This paper focuses on the experience of a recent series of 103 consecutive orthognathic cases treated by one surgeon with a surgical-orthodontic, speech-oriented approach. It will concentrate on not only correcting the occlusion, as others have described, but also on how a surgeon who was trying to achieve optimal aesthetic balance, harmony, and beauty, approached this problem.

Utilization of three-dimensional computed tomography for craniofacial phenotypic analysis in children with velocardiofacial syndrome.

OBJECTIVES: To analyze variants of the craniofacial phenotypes in children with velocardiofacial syndrome (VCFS) and children with cleft palates with a new protocol of landmarks using a three-dimensional computed tomography (CT)-reconstructed model in a cross-sectional group experimental design. MATERIALS AND METHODS: We present a retrospectively reviewed case series of 21 patients with VCFS, verified by short-tandem repeat techniques, and 20 children with cleft palate with age- and sex-matched controls from the Craniofacial Cleft Department of Oral and Maxillofacial Surgery of the 9th Shanghai People's Hospital. The records during the period between January 2005 and December 2008 were analyzed. The sample population of 41 children in this study was scanned with spiral CT. These images were reconstructed into three-dimensional models by SimPlant 11.2 and were analyzed with a new protocol of landmarks to test the variants of craniofacial phenotypes. RESULTS: All of the children with VCFS demonstrated velopharyngeal incompetence and craniofacial deformities. Measurements in the standard coordinate system demonstrated significant shorter cranial base, cervical vertebrae, longer maxilla height, and palatal angle. For the velopharyngeal variants, greater depth but lesser width of the pharyngeal cavity was shown in the VCFS group. CONCLUSIONS: Three-dimensional CT can provide precise data on craniofacial variants in children with distinctive morphologic features of VCFS.

Reviewing the orthognathic surgical care of the patient with cleft lip and palate: the single surgeon experience.

Patients with cleft lip and palate are best treated in a multidisciplinary setting and benefit from being treated by experienced surgeons in high-volume centers. We present the evaluation of 103 consecutive patients with cleft lip and palate treated by a senior craniofacial surgeon. The results of orthognathic surgery in respect to function, stability, cosmesis, and complications are audited.

Oral ectomesenchymal chondromyxoid tumor: case report and literature review.

Ectomesenchymal chondromyxoid tumor (ECMT) of the oral cavity is a rare lesion. We describe the 33rd reported case in the current English-language literature. This patient had originally presented 5 years earlier with a tongue neoplasm with biopsy results consistent with nerve sheath myxoma. A general surgical pathologist gave the patient's current lesion a preliminary diagnosis of low-grade sarcoma. After further evaluation by an oral and maxillofacial pathologist, the diagnosis of ectomesenchymal chondromyxoid tumor was established. It is important for clinicians to have a better understanding of ECMT, so as to avoid future misdiagnosis of this entity.

Dental premedication protocols for patients with knee and hip protheses.

In 1997, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) published an advisory statement regarding antibiotic prophylaxis for patients with total joint replacements undergoing dental treatment. The first periodic update of these guidelines was published in 2003. Nevertheless, confusion exists among dentists and physicians as to the clinical indications for premedication in this patient population. This article serves as an overview of current recommendations for use of chemoprophylaxis in the dental treatment of patients ith prosthetic joints.

Dental premedication protocols for patients with knee and hip prostheses.

In 1997, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) published an advisory statement regarding antibiotic prophylaxis for patients with total joint replacements undergoing dental treatment. The first periodic update of these guidelines was published in 2003. Nevertheless, confusion exists among dentists and physicians as to the clinical indications for premedication in this patient population. This article serves as an overview of current recommendations for use of chemoprophylaxis in the dental treatment of patients with prosthetic joints.

Medicaid children. A vulnerable cohort.

Vulnerable populations face special problems in dealing with the complexities of our fragmented health care delivery system, creating impediments to timely and effective care. Persistent differences in health status, utilization and outcomes exist among racial/ethnic groups, among age groups and between the sexes. Children are one specific cohort that serves as an unfortunate example of vulnerability within this system. This paper reviews some of the barriers that exist in access to care for Medicaid children.

Orthodontically guided eruption of mandibular second premolar following enucleation of an inflammatory cyst: case report.

This case study describes the surgical management of an inflammatory cyst combined with the orthodontically assisted eruption of an impacted mandibular second premolar.