Management of recurrent aphthous ulcers with therapeutic Nd:YAG laser, using two different methods.

BACKGROUND: Low-level laser therapy (LLLT) has been applied for the management of craniomaxillofacial disorders, including intraoral wounds, as well as recurrent aphthous stomatitis (RAS) lesions. However, the proper combination of laser features and tissue characteristics remains the major challenge in the realm of photobiomodulation (PBM). OBJECTIVES: The aim of the present study was to assess the feasibility of neodymium-doped yttrium aluminum garnet (Nd:YAG) laser therapy in treating RAS lesions, and to compare 2 techniques, different with regard to the distance between the fiber tip and the ulcer. MATERIAL AND METHODS: A total of 138 patients (94 males and 44 females) with untreated RAS were divided into 3 groups: focused laser (energy density: 48 J/cm2; power density: 0.797 W/cm2; spot size: 0.1256 cm2); defocused laser (energy density: 21 J/cm2; power density: 0.354 W/cm2; spot size: 0.2826 cm2); and placebo. In the focused group, laser irradiation was performed with the laser tip kept 1 mm away from the lesion. Acrylic cylinders were prepared to precisely fit the handpiece tip and hold it in the proper position. In the defocused group, acrylic cylinders were prepared to set the laser tip 6 mm away from the lesion to obtain defocused irradiation. Finally, in the placebo group, a routine laser therapy procedure was carried out with a helium-neon (He-Ne) red light laser. The lesion size, and pain intensity and duration were recorded. RESULTS: Photobiomodulation showed a significantly more efficient pain relief as compared to the placebo group (p < 0.001) and also significantly better results in decreasing pain duration (p < 0.001). Besides, the diameter of the lesions in the exposed cases decreased during the 3 consecutive days of the study, while an increase in the diameter of the lesions was noticed in the placebo group. CONCLUSIONS: The Nd:YAG laser therapy, with the conditions and adjustments of the present study, may be successfully applied to manage RAS lesions, using either focused and defocused scanning techniques.

An Overview of Maxillofacial Approaches to Smile Design.

The oral and maxillofacial surgeon (OMS) has the knowledge and skills to make drastic skeletal changes in favor of a more cosmetic smile. OMS can alter intraoral and extraoral soft tissues to make subtle or significant changes in facial cosmesis. This article provides an overview of the scope of the OMS in smile design. The authors provide a cursory review of pertinent gross and surgical facial anatomy, discuss the role of orthognathic surgery and rhinoplasty in smile cosmesis, and describe the fundamentals of common cosmetic procedures ranging from gingivoplasty to lip lift and lip augmentation and the use of neurotoxins.

Predictors of Nonsentinel Lymph Node Metastasis in Cutaneous Melanoma: A Systematic Review and Meta-Analysis.

BACKGROUND: Although completion lymph node dissection (CLND) is not routinely performed for a positive sentinel lymph node (SLN) anymore, adjuvant therapy depends on the risk factors available from SLN biopsy, including the risk of nonsentinel node metastases (NSNM). A systematic review and meta-analysis was performed in an attempt to identify risk factors that could be used to predict the risk of NSNM. MATERIALS AND METHODS: Medline, Web of Science, Embase, and Cochrane were searched for articles discussing predictive factors for NSNM. PRISMA guidelines were followed, and RevMan software was used to calculate pooled odds ratios (OR) using the Mantel-Haenszel test. RESULTS: Fifty publications were suitable for additional analysis. The clinical and primary tumor factors that were consistently identified as risk factors for NSNMs were: age >50, T stage 3 or 4, Clark level IV/V, ulceration, microsatellitosis, lymphovascular invasion, nodular histology, and extremity versus trunk primary tumor location. SLN factors that predicted NSNMs were >1 positive SLN, SLN micrometastatic tumor burden, diameter >2 mm, extracapsular extension, nonsubcapsular location (Dewar), and Rotterdam > 1 mm or ≥ 0.1 mm. CONCLUSIONS: The findings in this study support that many clinical and pathologic risk factors that can be assessed with SLN biopsy alone can be used to predict the risk of NSNMs. The factors identified in this review should be evaluated in clinical prediction models to predict the risk of NSNMS, a prediction that may be used to select patients for adjuvant therapy in high-risk melanoma.

Surgically Assisted Rapid Palatomaxillary Expansion With or Without Pterygomaxillary Disjunction: A Systematic Review and Meta-Analysis.

PURPOSE: The purpose of this review was to evaluate the outcome measurements of anterior expansion, posterior expansion, and complications after surgically assisted rapid palatal expansion (SARPE) with or without pterygomaxillary disjunction (PMD). MATERIALS AND METHODS: A computerized database search was performed using PubMed, CINAHL, Cochrane, Scopus, and Web of Science. Then, a computerized search was conducted in Google Scholar and ProQuest to overcome publication bias. RESULTS: From the original 125 combined results, 3 met the inclusion criteria. The Quality Assessment Tool for Quantitative Studies of the Effective Public Health Practice Project assessed 2 articles as weak and 1 as moderate. The systematic review included a total of 48 patients (11 male and 37 female). For 25 patients, SARPE was performed with PMD and for 23 patients SARPE was performed without PMD. A tooth-borne fixed hyrax-type palatal expansion screw appliance was used for all cases, activated 1 to 2 mm intraoperatively, and, after a latency period of 3 to 7 days, activated 0.5 to 0.6 mm per day for 38 patients and 0.25 mm for the other 10 until adequate expansion. Postexpansion retention was performed using ligature wired hyrax in 18 patients for 4 months. Comparisons were based on cone-beam computed tomographic projections, study models only, or a combination of study models, anteroposterior cephalometric radiographs, and occlusal radiographs. The time to measure the changes ranged from before fixed orthodontic retention to 6 months after the completion of active expansion. A meta-analysis was possible only for anterior (intercanine) and posterior (inter-molar) dental expansions. CONCLUSION: The literature is inconclusive regarding the effect of PMD on the outcomes of SARPE. Further controlled trials are needed.

Intraosseous heat generation during sonic, ultrasonic and conventional osteotomy.

OBJECTIVES: To assess heat generation in osteotomies during application of sonic and ultrasonic saws compared to conventional bur. METHODS: Two glass-fiber isolated nickel-chromium thermocouples, connected to a recording device, were inserted into fresh bovine rib bone blocks and kept in 20 ± 0.5 °C water at determined depths of 1.5 mm (cortical layer) and 7 mm (cancellous layer) and 1.0 mm away from the planned osteotomy site. Handpieces, angulated 24-32°, were mounted in a vertical drill stand, and standardized weights were attached to their tops to exert loads of 5, 8, 15 and 20 N. Irrigation volumes of 20, 50 and 80 ml/min were used for each load. Ten repetitions were conducted using new tips each time for each test condition. The Mann-Whitney-U test was used for statistical analysis (p < 0.05). RESULTS: Both ultrasonic and sonic osteotomies were associated with significantly lower heat generation than conventional osteotomy (p < 0.01). Sonic osteotomy showed non-significantly lower heat generation than ultrasonic osteotomy. Generated heat never exceeded the critical limit of 47 °C in any system. Variation of load had no effect on heat generation in both bone layers for all tested systems. An increased irrigation volume resulted in lower temperatures in both cortical and cancellous bone layers during all tested osteotomies. CONCLUSION: Although none of the systems under the conditions of the present study resulted in critical heat generation, the application of ultrasonic and sonic osteotomy systems was associated with lower heat generation compared to the conventional saw osteotomy. Copious irrigation seems to play a critical role in preventing heat generation in the osteotomy site.

Trigeminocardiac reflex: the current clinical and physiological knowledge.

The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hypermotility during stimulation of any of the sensory branches of the trigeminal nerve. Clinically, the TCR has been reported in all the surgical procedures in which a structure innervated by the trigeminal nerve is involved. Although, there is an abundant literature with reports of incidences and risk factors of the TCR; the physiological significance and function of this brainstem reflex has not yet been fully elucidated. In addition, there are complexities within the TCR that requires examination and clarification. There is also a growing need to discuss its cellular mechanism and functional consequences. Therefore, the current review provides an updated examination of the TCR with a particular focus on the mechanisms and diverse nature of the TCR.

Immediate effects of different steps of rhinoplasty on nasolabial angle and tip projection.

Nasolabial angle (NLA) and nasal tip projection (NTP) play an important role in aesthetic nose surgery. Little deviations can determine success and failure. The goal of this study was to analyze the immediate effect of different steps of open rhinoplasty on NLA and NTP. In this prospective single-blind study, 50 consecutive rhinoplasty cases were considered. The study consisted of 38 women and 12 men. The mean age was 28 years, ranging from 17 to 37 years. A standard life-size photograph was taken in each step of a classic open rhinoplasty during surgery. Nasolabial angle and NTP were measured and analyzed. Nasolabial angle: average increase after skeletonization (2.26 degrees), strut insertion (4 degrees), and tip spanning (0.17 degrees), whereas cephalic resection caused a decrease (1.9 degrees). Nasal tip projection: average increase after skeletonization (0.1 mm), strut insertion (0.31 mm), and tip spanning (0.84 mm), whereas cephalic resection caused a decrease (0.53 mm). Whereas strut insertion caused the highest mean increase in NLA, tip spanning was the most effective regarding change of NTP. Expectably cephalic resection was associated with decrease in NLA and NTP.

Bisphosphonates and connexin 43: a critical review of evidence.

Bisphosphonates (BPs) are drugs commonly used in the treatment of various disease arising or affecting bone tissue. There is a standard use in bone neoplasia and metastasis, hormonal and developmental disorders as well as for compensation of adverse effects in several medical therapies. Many in-vivo and in-vitro studies have assessed the efficacy of this drug and its function in cellular scale. In this concern, BPs are described to inhibit the resorptive function of osteoclasts and to prevent apoptosis of osteoblasts and osteocytes. They can preserve the osteocytic network, reduce fracture rate, and increase the bone mineral content, which is therapeutically used. Connexin 43 (Cx43) is a crucial molecule for basal regulation of bone homeostasis, development, and differentiation. It is described for signal transduction in many physiological and pathological stimuli and recently to be involved in BP action.

Current state of the effectiveness of problem-based learning in prosthodontics: a systematic review.

The aim of this study was to systematically review the available literature on the effectiveness of problem-based learning (PBL) in prosthodontics. Both electronic and manual searches were performed by two reviewers. Of the 440 studies identified, ten met the inclusion criteria (Kappa=0.83). Various assessment tools such as standardized examinations (National Board Dental Examination and North East Regional Board of Dental Examiners exam) (22 percent), tutor evaluation (practical and examinations performance) (20 percent), curriculum time (20 percent) and number of units (10 percent), peer evaluation (10 percent), and self-evaluation (100 percent) were used in the included studies. Thirty percent of the studies adopted a control group for all measurements, 30 percent did for only some measurements, and the others lacked any control group. Although 30 percent of the studies implemented a hybrid PBL, the other studies did not mention the type of PBL. Based on the Effective Public Health Practice Project (EPHPP), all of the included studies were rated as being of weak quality. Heterogeneity across these studies in outcome variables, study designs, levels of PBL intervention, and study population limits any attempt to generalize the outcomes. The generally poor quality assessment outcomes warrant further studies on the effectiveness of PBL in prosthodontics education compared to a non-PBL curriculum.

Problem-based learning in dental education: a systematic review of the literature.

The purpose of this systematic review was to compare the effectiveness of problem-based learning (PBL) with that of traditional (non-PBL) approaches in dental education. The search strategy included electronic and manual searches of studies published up to October 2012. The PICO (Population, Intervention, Comparator, and Outcome) framework was utilized to guide the inclusion or exclusion of studies. The search strategy identified 436 articles, seventeen of which met the inclusion criteria. No randomized controlled trial was found comparing the effectiveness of PBL with that of lecture-based approach at the level of an entire curriculum. Three randomized controlled trials had evaluated the effectiveness of PBL at a single course level. The quality assessment rated four studies as being of moderate quality, while the other studies were assessed as being of weak quality. This review concludes that there are a very limited number of well-designed controlled studies evaluating the effectiveness of PBL in dental education. The data in those studies reveal that PBL does not negatively influence the acquisition of factual knowledge in dental students and PBL enhances the ability of students in applying their knowledge to clinical situations. In addition, PBL positively affects students' perceived preparedness.

Trigeminocardiac reflex: current trends.

Since the first introduction of the trigeminocardiac reflex (TCR) in 1999, substantial new knowledge about this brainstem reflex has been created. First, by different clinical case reports and case studies, and second, from basic research that gives inputs from bench to bedside. In the present work, the authors therefore introduce the molecular/anatomical knowledge of the TCR and show its different connections to clinical aspects. Special reference is given to prevention and treatment of the TCR; but always with a link to knowledge of the basis sciences. In such a context different topics of future interest are introduced.

The effect of endotracheal tube cuff pressure control on postextubation throat pain in orthognathic surgeries: a randomized double-blind controlled clinical trial.

Pain in the throat after extubation is one of the most common complaints after maxillofacial operations under general anaesthesia. We have evaluated the amount of pain after extubation when we controlled the pressure in the endotracheal cuff during operation by analysing the records of 43 patients who had maxillofacial operations under general anaesthesia. In the study group (n=20) the cuff pressure of the endotracheal tube was adjusted using a pressure gauge at the beginning of intubation and every hour during operation. In the control group (n=23), an experienced anaesthetist adjusted the pressure only at the beginning of the operation by palpating the pilot balloon. Throat pain was evaluated 1, 6, and 24h postoperatively on a visual analogue scale (VAS), and the pain scores in the control and study groups postoperatively was 5.3 (1.1) compared with 3.9 (1.5) (p=0.002); 4.5 (1.3) compared with 3.1 (1.5) (p=0.002); and 1.9 (1.1) compared with 1.6 (1.2) (p=0.4), respectively. The differences between the two groups at 1h and 6h postoperatively were significant, but that at 24h was not. Control of the cuff pressure of the endotracheal tube with a gauge at the beginning of the operation, and adjustment of the pressure during operation, can reduce postoperative complications such as throat pain.

Alloplastic mandibular reconstruction: a systematic review and meta-analysis of the current century case series.

BACKGROUND: Alloplastic mandibular reconstruction remains insufficiently predictable, with no systematic reviews to assess its scope and limitations. METHODS: The PubMed, CINAHL, EMBASE, and Web of Science databases were searched for English study reports, published in the current century, of mere alloplastic surgical reconstruction of mandibular ablative defects. RESULTS: In 14 articles, there were 944 patients, with a median age of 58.7 years (interquartile range, 53.2 to 62 years); 58.7 percent (interquartile range, 66.7 to 78.6 percent) were male. Cases of squamous cell carcinoma per study constituted 93.5 percent (interquartile range, 81.5 to 100 percent). Defects were mostly lateral (Boyd classification) (60.5 percent; interquartile range, 56.2 to 62 percent) and received mostly conventional bridging plates (in 64.3 percent of the studies) and pedicled flaps (45.3 percent; interquartile range, 37.1 to 58.3 percent); 60.7 percent (interquartile range, 53.5 to 58.8 percent) received adjuvant therapy. At 32-month follow-up, the complication and failure rates were 40.1 percent (interquartile range, 26.7 to 58.6 percent) and 30.8 percent (interquartile range, 11.7 to 48.1 percent), respectively. The overall survival rate was 55 percent (interquartile range, 27.8 to 74 percent). Radiotherapy seemed to be a relative risk factor for complications (1.387; p = 0.014) and plate loss (1.585; p = 0.006). Crossing the midline seemed to be a relative risk factor for plate exposure (1.533; p = 0.000) and overall complications (1.385; p = 0.002). CONCLUSIONS: The results should be generalized cautiously. Alloplastic reconstructive surgery faces a remarkable lack of evidence. Relatively high complication and failure rates are areas of further concern.

Long-term outcome assessment of closed treatment of mandibular fractures.

Mandibular fractures are among the most common trauma injuries of the craniomaxillofacial region. This study evaluated the late results of mandibles fractures treated with arch bar. Forty-nine patients were examined clinically and by questionnaires for late results of arch bar treatment. Demographic data (age, sex, etc), trigeminal nerve sensation (Weber test), temporomandibular joint evaluation, masticatory muscle function, and occlusion were recorded. The data were analyzed by χ test using Sigma Stat 2.0 software. Fifty-one percent of the patients with angular fractures complained of sensory disturbances. Condylar and angular fractures demonstrated higher levels of pain. According to Pearson χ test, a statistically significant relation between angular fracture and tenderness of the internal pterygoid muscles (P = 0.047), angular fracture and cross-bite (P = 0.021), parasymphysial fracture and pain upon wind blowing (P = 0.026), and body fracture and mastication discomfort (P = 0.038) was found. In closed reduction therapy, fracture location of the mandible seems to be more likely correlated in producing particular long-term complications. Regular follow-ups for functional treatments and physiotherapy of chewing muscles and temporomandibular joint, along with removal of occlusal abnormalities, should be considered following arch bar reduction of mandibular fractures.

Neck hairline incision for simultaneous harvesting of temporal and mastoid fasciae: a technical note.

Fasciae are known reservoirs of ideal graft material. The temporalis and mastoid fasciae are 2 of the most important graft reservoirs used by plastic surgeons, otolaryngologists, and oral and maxillofacial surgeons. The temporalis fascia is harvested predominantly by plastic surgeons, whereas otolaryngologists often prefer the mastoid fascia. In either case, graft harvesting might be accompanied by donor-site complications, such as hair loss, bleeding, hematoma, and scar formation, which can limit its application. To gain access to the temporal and mastoid fasciae simultaneously, the authors combined conventional techniques to develop a modified single-approach incision line that would minimize most donor-site complications.

Comparative Microflora Assessment of Natural Sulci vs. Deep and Shallow Implant Sulci in Partial Edentulousness.

The main cause of peri-implantitis and crestal bone resorption is bacterial infection. The present study aimed to comparatively assess the microbiological parameters in sulci around teeth and crowns supported by dental implants and also compare microbiological parameters around deep and shallow implant sulci. In this cross-sectional study, 34 partially edentulous patients with a total of 72 implants (22 deep vs. 50 shallow sulci) were included. Excluded were the patients with compromised systemic and periodontal health or smoking habits. All Implants (ITI) were at least 6 month in place covered by definite prostheses. Samples of gingival sulci were taken around teeth and implants with paper points and transported in Stuart Transport Medium. Samples were cultured and examined by dark field microscope to determine the microorganisms. Data were evaluated statistically in SPSS (v11.5) using chi-square test. Cocci G+, Cocci G-, Prevotella, Porphyromonas gingivalis, Bacteroid fragilis and Fusobacterium were found. The relative frequency of P. gingivalis was significantly higher in deep implant sulci compared to shallow implant sulci (p = 0.044) and natural sulci (p = 0.009). B. fragilis was also significantly more isolated from the deep implant sulci compared to shallow implant sulci (p = 0.001) and natural sulci (p = 0.064). Within the limitations of the present study, it may be concluded that peri-implantitis is more likely in deep sulci compared with shallow sulci in partial edentulousness.

Material attrition and bone micromorphology after conventional and ultrasonic implant site preparation.

OBJECTIVES: Little is known about the recently introduced ultrasonic implant site preparation. The purpose of this study was to compare material attrition and micromorphological changes after ultrasonic and conventional implant site preparations. MATERIAL AND METHODS: Implant site preparations were performed on fresh bovine ribs using one conventional (Straumann, Freiburg, Germany) and two ultrasonic (Piezosurgery; Mectron Medical Technology, Carasco, Italy and Variosurg; NSK, Tochigi, Japan) systems with sufficient saline irrigation. Sections were examined by environmental scanning electron microscopy (ESEM). Energy-dispersive X-ray spectroscopy (EDX) was performed to evaluate the metal attrition within the bone and the irrigation fluid. RESULTS ESEM: After conventional osteotomy, partially destroyed trabecular structures of the cancellous bone that were loaded with debris were observed, whereas after ultrasonic implant site preparations, the anatomic structures were preserved. EDX: None of the implant site preparation methods resulted in metal deposits in the adjacent bone structures. However, within the irrigation liquid, there was significantly higher metal attrition with ultrasonic osteotomy (P < 0.0001 and P < 0.0001 for Mectron and NSK, respectively). Whereas for Straumann system used, 15.5% of the SEM/EDX findings were drill-origin metals, this percentage increased to 37.3% and 37.9% with the application of Mectron and NSK, respectively. CONCLUSIONS: Ultrasonic implant site preparation is associated with the preservation of bone microarchitecture and with the increased attrition of metal particles. Therefore, copious irrigation seems to be even more essential for ultrasonic implant site preparation than for the conventional method.

Lateral crural transposition flap in tip correction: Tehran retrospective rhinoplasty experience.

PURPOSE: This study aims to review the authors' experience with the lower lateral crura (LLC) transposition flap in an attempt to highlight its advantages, indications, and limitations. MATERIALS AND METHODS: A retrospective study of 37 rhinoplasties (29 primary cases, 7 secondary cases, and 1 tertiary case) was performed. In all of these, an LLC transposition flap was used by inserting the cephalic portion of the LLCs into a subperichondrial pocket between the medial aspect of the remaining rim strip and the vestibular skin, based on the posterior pedicle. RESULTS: The most prevalent symptom among our patients was nasal external valve dysfunction. Concavity of the LLCs was very common. The LLC transposition flap can correct the LLC deformities with a high rate of patient satisfaction and no need for revision operations. CONCLUSIONS: The LLC transposition flap can overcome the common irregularities of the LLCs and could be applied to primary and secondary rhinoplasties, as well as ethnic noses.

Freeman-Sheldon syndrome: combined surgical and non-surgical approach.

BACKGROUND: Many Freeman-Sheldon syndrome patients suffer from extensive microstomia resulting in possible inhibition of dental and skeletal development as well as difficulties in eating, speech and dental hygiene. Oral commissure contraction treatments vary from patient education to complicated surgical and/or prosthetic treatments, but recurrence is often described. This article reports on a combined surgical and non-surgical approach in order to increase maximum mouth opening and maintain the result of the surgery. TECHNIQUE: The patient underwent bilateral commissuroplasty using 2 rhomboid flaps for each side. After two steps of intraoral and perioral tissue impression taking, a master cast was poured and a retractor was fabricated from thermoplastic material. The patient was encouraged to wear the retractor the entire day and night except at meal times. RESULTS: After surgery maximum mouth opening was increased from 20 mm to 37 mm and remained the same six months after the surgery. Psychosocial factors were improved and the patient was satisfied with the results of her treatment. CONCLUSION: The use of bilateral commissuroplasty in combination with this customized dynamic oral commissure retractor may be applicable in other syndromic patients with a small oral commissure and also in patients with circumoral burns.