Dental arcade arteriovenous fistulas: from diagnosis to treatment with emphasis on the role of endovascular or percutaneous treatment: single centre experience.

OBJECTIVE: Dental arcade arteriovenous fistula (DA-AVF) are rare. The purpose of this study was to understand the angioarchitecture of these lesions, changing strategies of endovascular treatment and to analyse the best therapeutic option which will allow normal skeletal development especially in children. MATERIALS AND METHODS: Retrospective study of all the patients of DA-AVF managed at our centre over the last 16 years. Detailed analysis of the clinical features, the imaging findings, endovascular treatment and angiographic outcomes was done. RESULTS: Total of six patients were treated. 5 were in the mandible and one in the maxilla. Transarterial glue embolization was done in 3 patients and direct puncture of the intraosseous venous pouch in 2. Transarterial Onyx was used in 2 patients through dual lumen balloon catheter. Overall cure was achieved in 5 out of 6 patients (83%). CONCLUSION: High index of suspicion is required to diagnose it on panoramic radiographs. CT/MR/CTA can lead to early diagnosis. Transarterial Onyx embolization using dual lumen balloon catheter is a promising technique & allows excellent penetration of Onyx into the intraosseous venous pouch.

The modified "Wunderer" osteotomy for stabilization of the cleft-premaxilla--a new operative technique.

The operative closure of bilateral cleft lip and palate is a difficult procedure that requires in most cases secondary corrections. Besides aesthetic improvements of lip and nose also the rehabilitation of the teeth, in particular of the maxillary arch is important for the improvement of the chewing function and also for the well being of the patient. One of the most disturbing factors for the construction of any type of prosthetic devices, like removable denture, fixed bridge or dental implants is the mobility and often also malposition of the premaxilla. This problem can only be solved by the insertion of bone grafts into the bilateral gaps of the anterior maxillary arch. This procedure however, is difficult due to the narrowness and poor overview that complicates the closure of the nasal mucosa, which is the precondition for the success. For facilitating the operation the premaxilla is osteotomized and reflected anteriorly according to the method of Wunderer (1962). Then, after the much easier closure of the nasal mucosa the bony defects can be filled with autogenous cancellous bone and finally the oral mucosa can be closed. A preoperatively prepared palatal acrylic plate helps to protect the palatal tissue and also stabilizes the position of the premaxilla. The blood supply to the osteotomized premaxilla is secured by a sound soft tissue pedicle of the buccal muco-periosteum. The effectiveness of the blood supply of the premaxilla was examined in experimental studies by several authors. Also investigations of the growth impediments of the premaxilla and the midface revealed that early osteotomies will interfere with the development of this region. Therefore it is advisable to carry out this procedure not before the patient has reached the age of 12-14 years, which is also depending on the race and the gender of the patient.

Variations of vascular distribution in the mandibular anterior lingual region: a high risk of vascular injury during implant surgery.

PURPOSE: To clarify variations of vascular distribution around the mandibular anterior tooth lingual region, an area in which vascular injuries have often been reported during dental implant surgery. The reasons for such injuries in this region are discussed from an anatomical perspective. MATERIALS AND METHODS: Anatomical dissections were performed on 100 sides of 50 cadavers used for anatomy education. Ten sides of 5 cadavers were injected intravascularly with methyl methacrylate, and penetration of the mandible was closely evaluated. RESULTS: In the mandibular anterior tooth lingual region, both the sublingual and submental arteries showed various distribution patterns. Distal branches basically penetrated the bone. CONCLUSIONS: In the mandibular anterior tooth lingual region, the sublingual and submental arteries traveled from the vicinity of the mylohyoid muscle attachment along the bone surface in an anterosuperior direction. Many of these blood vessels penetrated the alveolar mucosa in the anterior tooth region, and many distal branches of the vessels also finally penetrated the bone. This seems to explain why many vascular injuries are encountered around the mandibular anterior tooth lingual region during implant surgery.

Morphometrical and morphological study of mental foramen in dry dentulous mandibles of South Andhra population of India.

BACKGROUND: Mental foramen (MF) is an anatomical structure of particular importance in local anesthesia and surgical procedures in terms of achieving effective mandibular nerve blocks and avoiding injuries to the neurovascular bundles. AIM: To determine the morphometry and morphology of MF in south Andhra population of India, hitherto unreported. MATERIALS AND METHODS: Ninety dry dentulous mandibles of both sexes were examined for position, size, shape and number of MF. RESULTS: Various parameters investigated are, the horizontal distance between (1) symphysis menti and MF was 27.2 mm on right and 27.7 mm on the left, (2) MF and posterior border of ramus was 70.7 mm on both sides, vertical distance between (3) MF and inferior border of mandible was 16.5 mm on right and 14.3 mm on left, (4) alveolar crest and MF was 13.7 mm on right and 16.4 on left, (5) distance between the MF and below the apex of premolar socket was +2.8 mm on right and +3.5 mm on left and above the socket was -2.8 mm on right and -2.7 mm on left. Occurrence of MF below the second premolar tooth was found to be highest (73.2%). Average size of MF was larger on left and its way of exit was in postero-superior direction. Shape of MF was round in 79% and oval in 21% and double MF was found in 8.9% of mandibles. CONCLUSIONS: In the present study, most common position of MF was found below the apex of second premolar in 73.2% and between the second premolar and first molar in 19% of mandibles. The other morphometrical findings of this study may be implicated by dental practitioners and maxillofacial surgeons.

Lingual vascular canal assessment by dental computed tomography: a retrospective study.

BACKGROUND: Lingual vascular canal (LVC) is an important anatomical structure in mandibular anterior region. Trauma to this structure during implant placement has been reported in this study. Dental computed tomography (DCT) provides a three-dimensional visualization of lingual vascular canal. AIM: To assess the frequency, location, and size of LVC using dental CT. MATERIALS AND METHODS: A retrospective analysis of 75 mandibular DCT was done. Evaluation was done to detect the frequency, size, and number of lingual vascular canal using Seimens Somatom Sensation 64. RESULTS: About 73.3% patients (male=34, female=21) demonstrated presence of LVC with only one patient showing two canals. The mean distance from the inferior border of mandible was 0.5 mm, S.D.±0.70. The mean diameter of the canal was 0.31 mm, S.D.±0.70. CONCLUSION: Dental CT provides adequate information regarding frequency, number, and size of lingual vascular canal, which is an important anatomical structure in mandibular anterior region.

An extraction socket classification developed using analysis of bone type and blood supply to the buccal bone in monkeys.

Bone modeling and remodeling following tooth extraction has been studied extensively. The reason for bone loss during the remodeling process is multifactorial, and the primary reason for this loss is still yet to be determined. The aim of this study was to examine the type of bone and the blood supply to the buccal bone in monkeys. Six maxillary arches from six monkeys were used. The arches were divided into three sections: right posterior, anterior from canine to canine, and left posterior. Blocks were decalcified and prepared for histologic processing and examination. Modified Masson trichrome and retic staining were used. Histologic sectioning demonstrated that the blood supply to the buccal bone came from the inner (socket) side of the alveolus, the periodontal ligament, the adjacent interdental bone, and the supraperiosteal vessels emanating from the covering gingiva or mucosa. Histologic examination showed that the buccal bone was composed of bundle and cortical bone. The thickness of the buccal bone was not uniform coronoapically, and the thinnest area of buccal bone was the coronal portion.

The accuracy of identifying the greater palatine neurovascular bundle: a cadaver study.

BACKGROUND: The palate is a common site for harvesting subepithelial connective tissue grafts (SCTG). The size of SCTG that can be harvested is dictated by the position of the greater palatine neurovascular bundle (GPB). The aims of this cadaver study are to assess the accuracy of predicting the location of the GPB on study models and to evaluate anatomic factors that might influence the predictability. METHODS: Eleven fully dentate or partially edentulous maxillary cadavers were used. Study models were fabricated after the greater palatine foramen was identified. The GPB was recognized after dissection, from which the distance to the cemento-enamel junction of the first molar and premolar was measured. Eight periodontists and twelve periodontal residents were asked to estimate the location of the GPB on the study models and the same measurements were taken. Comparisons of the estimated and true GPB position were performed. The correlation between the palatal vault height and the variability of detecting the GPB was investigated. RESULTS: The most frequent greater palatine foramen location was between the second and third molars (66.6%). For most cases, there was an underestimation of the location of the GPB up to 4 mm. The interexaminer variability was positively correlated with the vault height. CONCLUSIONS: The estimated location of the GPB was commonly closer to the cemento-enamel junction of posterior teeth. Agreement on the location of the GPB was lowered with the presence of high palatal vaults. The results of this study could assist clinicians in planning the location for harvesting SCTG on the hard palate.

Evaluation of vascular endothelial growth factor (VEGF) in interradicular bone marrow in olpadronate treated animals

Vascular endothelial growth factor (VEGF) is a protein that increases vascular permeability and induces the proliferation, migration and survival of endothelial cells. Bisphosphonates (BPs) are antiresorptive drugs that are widely used in the treatment of bone metabolism diseases and bone metastases. Since 2003, cases of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have been reported. Few papers explain the mechanisms that induce BRONJ; some authors mention alterations in bone remodelling and a certain antiangiogenic effect of BPs. The aim of this study is to evaluate the expression of VEGF in bone marrow cells and the number of blood vessels and area occupied by them in animals treated with the BP sodium olpadronate (OPD). We used 16 Wistar rats, 60 days old, divided into two groups, experimental (OPD) and control. The OPD group received 0.3 mg/kg/week intraperitoneal OPD for 5 weeks. The control group received an equivalent intraperitoneal volume of physiological saline solution. After euthanasia, hemimandibles were processed and mesio-distal histological sections of the first molar were prepared. Sections were stained with hematoxylin-eosin (HE), immunohistochemical detection of VEGF was performed (sc- 7269) and the following histomorphometric parameters were evaluated: In HE-stained sections - number of blood vessels per sq. mm. and percentage (%) of area occupied by blood vessels in relation to total area evaluated; in sections with immunohistochemical detection of VEGF – number of VEGF+ bone marrow cells per sq. mm. Data underwent statistical analysis. Number of blood vessels/mm2 was significantly lower in the OPD group (OPD: 92 ± 16; Control: 140 ± 31; p<0.05) and % vascular area/ total area evaluated showed no significant difference (OPD: 15.6 ± 6.1; Control: 10.2 ± 4.2). Number of VEGF+ cells/mm2 was lower in the OPD group than in the control group, with statistically significant differences (OPD: 7804.8 ± 597; Control: 13187.6 ± 894; p<0.001). The results of this study suggest that monosodium olpadronate has an antiangiogenic effect. Further studies are needed to reveal its potential as an antitumor agent and its connection with the onset of BRONJ.

El factor de crecimiento vascular (VEGF) es una proteina que incrementa la permeabilidad vascular, induce la proliferacion, migracion y supervivencia de las celulas endoteliales. Los bifosfonatos (BFs) son drogas antirresortivas ampliamente utilizadas en el tratamiento de enfermedades que alteran el metabolismo oseo y de metastasis oseas. Desde el 2003 se han reportado casos de osteonecrosis de maxilar asociada al uso de BFs (ONAB). Escasas publicaciones explican los mecanismos que inducen la ONAB, algunos autores mencionan las alteraciones en la remodelacion osea y un cierto efecto antiangiogenico de los BFs. El objetivo del presente trabajo es evaluar la expresion de VEGF en celulas de la medula osea y el numero y el area ocupada por vasos sanguineos en animales tratados con el BF olpadronato monosodico (OPD). Se utilizaron 16 ratas Wistar de 60 dias divididas en dos grupos, experimental (OPD) y control. El grupo OPD, recibio 0,3 mg/kg/sem de OPD via IP, durante 5 semanas. El grupo control, recibio un volumen equivalente via IP de solucion fisiologica. Luego de practicada la eutanasia se obtuvieron las hemimandibulas y se procesaron para obtener cortes histologicos mesio-distales del primer molar. Se realizo la coloracion hematoxilina-eosina (HE) y la deteccion inmunohistoquimica de VEGF (sc-7269) y se evaluaron los siguientes parametros histomorfometricos: En cortes con H&E: Numero de vasos sanguineos por mm2 y porcentaje (%) de area ocupada por los vasos sanguineos en relacion al area total evaluada; en cortes con la deteccion inmunohistoquimica de VEGF: Numero de celulas medulares VEGF+ por mm2. Los datos fueron estadisticamente analizados. El N° vasos sanguineos/mm2 fue significativamente menor en el grupo OPD (OPD: 92 ± 16; control: 140 ± 31; p<0,05) y el % area vascular/area total evaluada no mostro diferencias significativas (OPD: 15,6 ± 6.1; Control: 10.2 ± 4.2). El N° de celulas VEGF+/mm2 en el grupo OPD fue menor que en el grupo control con diferencias estadisticamente significativas (OPD: 7804,8 ± 597; Control: 13187,6 ± 894; p<0,001). Los resultados de este estudio sugieren que el olpadronato monosodico tiene un efecto antiangiogenico. Futuros estudios revelaran su potencial como agente antitumoral asi como tambien su relacion con la aparicion de ONAB.

Evaluation of vascular endothelial growth factor (VEGF) in interradicular bone marrow in olpadronate treated animals.

UNLABELLED: Vascular endothelial growth factor (VEGF) is a protein that increases vascular permeability and induces the proliferation, migration and survival of endothelial cells. Bisphosphonates (BPs) are antiresorptive drugs that are widely used in the treatment of bone metabolism diseases and bone metastases. Since 2003, cases of bisphosphonate-related osteonecrosis of the jaw (BRONJ) have been reported. Few papers explain the mechanisms that induce BRONJ; some authors mention alterations in bone remodelling and a certain antiangiogenic effect of BPs. The aim of this study is to evaluate the expression of VEGF in bone marrow cells and the number of blood vessels and area occupied by them in animals treated with the BP sodium olpadronate (OPD). We used 16 Wistar rats, 60 days old, divided into two groups, experimental (OPD) and control. The OPD group received 0.3 mg/kg/week intraperitoneal OPD for 5 weeks. The control group received an equivalent intraperitoneal volume of physiological saline solution. After euthanasia, hemimandibles were processed and mesio-distal histological sections of the first molar were prepared. Sections were stained with hematoxylin-eosin (HE), immunohistochemical detection of VEGF was performed (sc-7269) and the following histomorphometric parameters were evaluated: In HE-stained sections--number of blood vessels per sq. mm. and percentage (%) of area occupied by blood vessels in relation to total area evaluated; in sections with immunohistochemical detection of VEGF--number of VEGF+ bone marrow cells per sq. mm. Data underwent statistical analysis. Number of blood vessels/mm2 was significantly lower in the OPD group (OPD: 92 +/- 16; CONTROL: 140 +/- 31; p < 0.05) and % vascular area/total area evaluated showed no significant difference (OPD: 15.6 +/- 6.1; CONTROL: 10.2 +/- 4.2). Number of VEGF+ cells/mm2 was lower in the OPD group than in the control group, with statistically significant differences (OPD: 7804.8 +/- 597; CONTROL: 13187.6 +/- 894; p < .001). The results of this study suggest that monosodium olpadronate has an antiangiogenic effect. Further studies are needed to reveal its potential as an antitumor agent and its connection with the onset of BRONJ.

Clinical implications of the topography and distribution of the posterior superior alveolar artery.

The aim of this study was to clarify the arrangement of the anatomic courses and distribution of the intraosseous branch (IObr) of posterior superior alveolar artery. The anatomic variations in the topographic relationships were described to provide beneficial data to minimize injury to the IObr during surgical procedure of the buccal wall of the maxillary sinus. The IObrs in 42 hemifaces of embalmed Korean cadavers were examined. The courses of the IObr of the posterior superior alveolar artery were classified into 2 categories: the straight (type 1) and the U-shaped (type 2). The type 1 was the most common (78.1%), and the type 2 was observed in 21.9% of the specimens. The minimum mean height from the cervix to the IObr was 21.1 mm in the first molar region. The IObr ran at the lowest level from the maxillary sinus floor at the first premolar region. These anatomic findings in the current study could represent useful information for the various surgical procedures of the maxilla.

Assessment of vascularity in irradiated and nonirradiated maxillary and mandibular minipig alveolar bone using laser doppler flowmetry.

PURPOSE: The purpose of this animal study was to confirm that laser Doppler flowmetry (LDF) is a reproducible method for the assessment of maxillary and mandibular alveolar bone vascularity and that there is less vascularity in irradiated mandibular and maxillary bone compared to nonirradiated bone. MATERIALS AND METHODS: All maxillary and mandibular premolars and molars of 6 Göttingen minipigs were extracted. After a 3-month healing period, 3 minipigs received irradiation at a total dose of 24 Gy. Three months after irradiation, 5 holes were drilled in the residual alveolar ridge of each edentulous site in each minipig. Local microvascular blood flow around all 120 holes was recorded by LDF prior to implant placement. In 1 irradiated and 1 nonirradiated minipig, an additional hole was drilled in a right maxillary site to enable repeated LDF recordings. RESULTS: The alveolar bone appeared less vascularized in irradiated than in nonirradiated minipigs. The effect of radiation appeared more pronounced in the mandible than in the maxilla. LDF was demonstrated to be a reproducible method for assessing alveolar bone vascularity. However, recordings varied by edentulous site as well as by minipig. CONCLUSION: The authors' hypotheses regarding LDF and vascularity were supported. Further research validating the use of LDF in human beings, especially in those who have undergone radiation therapy for head and neck cancer, is necessary.

Arteriovenous malformations of the dental arcades. The place of endovascular therapy: results in 12 cases are presented.

Twelve arteriovenous malformations of the dental arcades (AVMDAs) (seven mandibular and five maxillary) were seen in our institution between 1977 and 1997. All these lesions consisted of true arteriovenous shunts (of either nidus or fistulous type) involving the bone, with or without soft tissue extension. Haemorrhage was present in eight patients (67%); either torrential, necessitating emergency embolization, or recurrent and progressive. Teeth instability was detected in all patients and was the origin of the bleeding. All lesions were embolized. Lesions in nine patients were embolized with Polyvinyl Alcohol Particles (PVA): this helped to stabilize the situation but could not avoid recurrences in all patients, necessitating complementary embolizations and or surgery. The use of acrylic glue (N-Butyl-Cyano-Acrylate [NBCA] Histoacryl) as the embolic agent has changed the results obtained tremendously. Eight patients have been treated with NBCA (five as complementary therapy to PVA during later sessions and three at the first attempt); injection either via the transarterial route or direct transcutaneous puncture (four patients) achieved a cure in four of these lesions (34%) with stability at long-term follow-up of all the other AVMs. Embolization with glue represents the therapy of choice in these sometimes life-threatening lesions, achieving a cure if directed towards the osseous venous lakes. Surgery, often leading to facial mutilation and necessitating massive reconstruction should be avoided nowadays, at least as the initial therapy.