Manejo terapéutico de la celulitis crónica circunscrita: a propósito de un caso clínico / Therapeutic Management Of Circunscribed Chronic Cellulitis: A Case Report

La celulitis crónica circunscrita es resulta-do de la persistencia de una lesión dentaria, bacterias de baja virulencia o una antibioterapia mal planteada. Se caracteriza por la presencia de un cordón fibroso, signo patognomónico, que debe ser elimina-do junto al foco causal. La clínica es poco llamativa y puede pasar desapercibida al paciente. Sin embargo, no está exenta de un posible proceso de agudización que dificulten su posterior tratamiento o que actúen como un foco infeccioso a distancia. Se presenta un caso de un paciente de 51 años que acude a consulta exudado de contenido purulento a través de una fistula extra-oral de un año de evolución. Se realizó la extracción de los dientes involucrados y se eliminó el cordón fibroso asociado. Se plantea junto al abordaje quirúrgico una pauta antibiótica de corta duración para prevenir la aparición de resistencias basado en la evidencia científica actual

Circumscribed chronic cellulitis is the result of the persistence of a dental lesion, bacteria of low virulence or poorly raised antibiotic therapy. It has been defined by the presence of a fibrous cord, a pathognomonic sign, which must be eliminated together with the causal focus.The clinic is inconspicuous and can go unnoticed to the patient. However, it is not exempt from a possible process of exacerbation that hinders its subsequent treatment or that acts as an infectious focus at a distance. We present a case of a 51-year-old patient who included an exudate consultation of purulent content through an extra oral fistula that had been one year old. The extraction of the involved teeth was performed and the associated fibrous cord was removed. It is presented with the surgical approach, a short-term medical practice to prevent the emergence of resistance based on current scientific evidence

Three-Dimensional Printing: A Novel Approach to the Creation of Obturator Prostheses Following Palatal Resection for Malignant Palate Tumors.

BACKGROUND: A subgroup of patients who have an oronasal fistula live in areas that have limited access to oral prosthetics. For these individuals, a temporary prosthesis, such as a palatal obturator, may be necessary in order to speak, eat, and breath properly. The creation of an obturator, which requires a highly trained prosthodontist, can take time and can be expensive. Through the current proof-of-concept study, there is an attempt to create a patient-specific palatal obturator through use of free and publicly available software, and a low-cost desktop 3-dimensional printer. The ascribed study may provide a means to increase global access to oral prosthetics if suitable biomaterials are developed. METHODS: Computerized tomography data were acquired from a patient who had an oronasal fistula. Through use of free software, these data were converted into a 3-dimensional image. The image was manipulated in order to isolate the patient's maxilla and was subsequently printed. The palatal obturator models were designed, and reformed, in correspondence with the maxilla model design. A final suitable obturator was determined and printed with 2 differing materials in order to better simulate a patient obturator. RESULTS: Creating a suitable palatal obturator for the specified patient model was possible with a low-cost printer and free software. CONCLUSIONS: With further development in biomaterials, it may be possible to design and create an oral prosthesis through use of low-cost 3-dimensional printing technology and freeware. This can empower individuals to attain good healthcare, even if they live in rural, developing, or underserviced areas.

Diagnostic imaging of oronasal fistulas in a dachshund.

Oronasal fistula development is described anecdotally as a common disease process in the dachshund but little is known about its imaging appearance. This case report describes the clinical presentation, computed tomography (CT) characterisation, dental radiograph confirmation and treatment of bilateral oronasal fistulas in a 14-year-old dachshund.

Spacer Facial Artery Musculomucosal Flap: Simultaneous Closure of Oronasal Fistulas and Palatal Lengthening.

UNLABELLED: In this series, the authors describe a modification of the facial artery musculomucosal flap for oronasal fistula repair. The spacer facial artery musculomucosal flap technique is characterized by a pedicle inset into the retromolar trigone and palate, obviating a second operative stage. This was performed in 14 patients with a 5.2-cm mean fistula size. Average follow-up was 4.3 years, with one partial flap necrosis but no recurrent oronasal fistula. There was a mean decrease of 18 percent in the distance between the velum and the posterior pharyngeal wall. The spacer facial artery musculomucosal flap provides a single-stage reconstruction of oronasal fistula while lengthening the palate through a pushback mechanism. Although further study of velopharyngeal function is needed, the spacer facial artery musculomucosal flap may be beneficial for patients with a short velum and an oronasal fistula. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Radiology of Cleft Lip and Palate: Imaging for the Prenatal Period and throughout Life.

Recent advances in prenatal imaging have made possible the in utero diagnosis of cleft lip and palate and associated deformities. Postnatal diagnosis of cleft lip is made clinically, but imaging still plays a role in detection of associated abnormalities, surgical treatment planning, and screening for or surveillance of secondary deformities. This article describes the clinical entities of cleft lip with or without cleft palate (CLP) and isolated cleft palate and documents their prenatal and postnatal appearances at radiography, ultrasonography (US), magnetic resonance (MR) imaging, and computed tomography (CT). Imaging protocols and findings for prenatal screening, detection of associated anomalies, and evaluation of secondary deformities throughout life are described and illustrated. CLP and isolated cleft palate are distinct entities with shared radiologic appearances. Prenatal US and MR imaging can depict clefting of the lip or palate and associated anomalies. While two- and three-dimensional US often can depict cleft lip, visualization of cleft palate is more difficult, and repeat US or fetal MR imaging should be performed if cleft palate is suspected. Postnatal imaging can assist in identifying associated abnormalities and dentofacial deformities. Dentofacial sequelae of cleft lip and palate include missing and supernumerary teeth, oronasal fistulas, velopharyngeal insufficiency, hearing loss, maxillary growth restriction, and airway abnormalities. Secondary deformities can often be found incidentally at imaging performed for other purposes, but detection is necessary because they may have considerable implications for the patient.

Computed tomography fistulography demonstrating thyroglossal fistula: a case report.

We report a case of thyroglossal fistula in a young male that was clearly demonstrated using computed tomography fistulography.

Asymptomatic patent nasopalatine ducts after rapid maxillary expansion.

This article describes the clinical case of a patient, a 13-year-old boy, in whom the appearance of patent nasopalatine ducts was noted after having a rapid maxillary expansion performed. To confirm this finding, inspection and radiographic examination were performed in which gutta-percha cones were used as contrast. The patient related no symptoms or discomfort due to the ducts. The patient was followed up for a period of 6 months, during which he was instructed as regards correct cleaning to prevent the accumulation of food and infection.

Formocresol versus calcium hydroxide direct pulp capping of human primary molars: two year follow-up.

OBJECTIVES: Clinical and radiographic evaluation of the premedicated direct pulp capping using formocresol (PDC) versus conventional direct pulp capping using calcium hydroxide (CDC) in human carious primary molars. STUDY DESIGN: A total of 120 vital primary molars with pinpoint exposure during caries removal in 84 patients aged 4-5 years were selected. In the PDC group (n = 60), 20% Buckley's formocresol solution, and in the CDC group (n = 60), calcium hydroxide powder were applied to the exposure sites followed by placement of zinc oxide-eugenol base. Teeth were restored with preformed stainless steel crowns. Clinical and radiographic evaluations of the treatment outcomes were performed at regular intervals of 6 and 12 months, respectively, for two years post-operatively. RESULTS: The prevalence of spontaneous pain, sensitivity on percussion, and fistula were significantly higher in the CDC group compared to the PDC group (P < 0.05). The number of teeth exhibiting periapical/furcal radiolucency or external/internal root resorption was also higher in the CDC group (P < 0.05). The clinical success rate of the PDC was 90% compared to the 61.7% of the CDC (P < 0.05). The radiographic success rates of the PDC and CDC groups were 85% and 53.3%, respectively (P < 0.05). CONCLUSION: It seems formocresol premedicated direct pulp capping could safely be used as a substitute for conventional direct pulp capping.

Radiographic findings in bisphosphonate-treated patients with stage 0 disease in the absence of bone exposure.

PURPOSE: Radiographic features in patients with bisphosphonate-related osteonecrosis of the jaw (BRONJ) are well described, but less is known in bisphosphonate-exposed individuals with stage 0 disease (clinical symptoms without exposed necrotic bone) considered at risk for BRONJ. We sought to characterize radiographic findings in a subgroup of patients with concerning clinical symptoms and bisphosphonate exposure to identify imaging features that may presage development of BRONJ. MATERIALS AND METHODS: A dental symptom survey was returned by 8,572 Kaiser Permanente Health Plan members receiving chronic oral bisphosphonate therapy, and 1,005 patients reporting pertinent dental symptoms or complications after dental procedures were examined. Those without BRONJ but with concerning symptoms were referred for clinical evaluation, including imaging. Among the subset who received maxillofacial imaging, we identified those with stage 0 disease and abnormal radiographic features. RESULTS: There were a total of 30 patients without exposed bone but with concerning symptoms who received maxillofacial imaging (panoramic radiography or computed tomography) in the context of clinical care. Among these 30 patients, 10 had stage 0 disease with similar radiographic features of regional or diffuse osteosclerosis in clinically symptomatic areas, most with extension beyond the involved site. Other findings in these 10 patients included density confluence of cortical and cancellous bone, prominence of the inferior alveolar nerve canal, markedly thickened and sclerotic lamina dura, uniform periradicular radiolucencies, cortical disruption, lack of bone fill after extraction, and a persisting alveolar socket. None had exposed bone develop during 1-year follow-up. The remaining 20 patients had normal or localized radiographic findings consistent with odontogenic pathology. CONCLUSION: In 10 of 30 symptomatic patients referred for clinical evaluation and imaging, a consistent finding was conspicuous osteosclerosis in clinically symptomatic areas characteristic of stage 0 disease. These data support the need to better understand radiographic features associated with bisphosphonate exposure and to determine whether osteosclerosis is a specific finding indicative of the risk for progression to BRONJ.

[The patent nasopalatine duct. A rare anomaly and diagnostic pitfall]. / Der offene Ductus nosopalatinus. Eine seltene Missbildung und diagnostische Falle.

The patent nasopalatine duct is a rare anomaly in the anterior maxilla. During the early fetal period, a bilateral and epithelium-lined duct is formed within the primary palatal process as an oro-nasal communication. However, the duct obliterates and degenerates before birth. A persisting patent or through-and-through nasoplatine duct is therefore considered a developmental anomaly. A patent nasopalatine duct normally presents as one (or two) tiny openings lateral or posterior to the incisive papilla. In such a case, the ducts can be partially or completely probed with gutta-percha points with subsequent radiographic imaging. The patients report strange sensations such as squeaking noise, palatal drainage, nasal regurgitation, or airway communication between nasal and oral cavities; however, patients rarely complain about pain. About 40 cases have been documented in the literature. We describe two patients who have been referred to our department for evaluation of "sinus tracts" in the anterior palate. Since a patent nasopalatine duct can become a diagnostic pitfall, a thorough inspection of the mucosa around the incisive papilla is essential to avoid unnecessary endodontic or surgical interventions in the area of the central maxillary incisors.

Reconstruction of an unusual orocutaneous fistula by using a bilobed flap.

Orocutaneous fistulas or cutaneous sinus tracts of dental origin are pathologic communications between the cutaneous surface of the face and the oral cavity. They are relatively uncommon and may be easily misdiagnosed. In this report, management of an orocutaneous fistula of dental origin, which endured for 20 years, by using an extraoral bilobed skin flap, an intraoral buccal rotational mucosal flap and allogenic bone graft, is presented.

Different clinical outcomes following root fractures of adjacent incisors: a case report.

AIM: To report different patterns of root fracture healing in adjacent maxillary central incisors with distinct post-treatment outcomes. SUMMARY: To describe the case of a 12-year-old girl who presented with an avulsed coronal fragment of tooth 11 and root fractures in the middle thirds of teeth 11 and 21. Four months after initial treatment, she was referred for specialized endodontic care. Tooth 11 presented no clinical or radiographic signs of pulp breakdown. However a sinus tract was found related to the middle root third of tooth 21, indicating pulp necrosis in the coronal fragment. The coronal fragment was root filled and periapical surgery was performed to remove the apical fragment. Twelve months after the clinical procedures and 16 months after trauma, hard tissue healing was evident in tooth 11 region. Bone healing was also satisfactory in the periapical region of tooth 21. *Even adjacent teeth may display different reaction patterns after trauma. *The prognosis of root fractures is variable and different clinical approach may be required to preserve teeth with fractured roots.

Submental cutaneous sinus tract as a result of progressive peri-implantitis: a case report.

BACKGROUND: The aim of the present case report was to define diagnosis and treatment options of a submental cutaneous sinus tract as a result of a progressive peri-implantitis around mandibular dental implants in a patient with a history of oral squamous cell carcinoma. METHODS: Before the removal of the submental fistula, a panoramic radiograph and a computed tomography of the head and neck were assessed to identify the implants responsible for the cutaneous sinus tract and to exclude the presence of a tumor recurrence and lymph node metastases. The involved implants were removed, as there was a communication along them between the oral cavity and the cutaneous sinus tract resulting from progressive peri-implantitis. A histological examination of the excised fistula was carried out. RESULTS: The histological examination excluded a recurrence of the oral squamous cell carcinoma. The fistula completely consisted of granulation tissue without epithelialization. After affected implants were removed, the wound healing was uneventful. CONCLUSIONS: A panoramic radiograph is mandatory to identify the involved implants. Computed tomography, and excision of the fistula and a histological examination should be performed only in patients with a history of oral squamous cell carcinoma. Since the cutaneous sinus tract showed no epithelialization, it healed spontaneously after the removal of the responsible implants. Because of the large bony defect caused by progressive peri-implantitis leading to a communication of the oral cavity with the cutaneous sinus tract, more conservative treatment options with preservation of the implants could not be adopted in the present case.

Clinical significance of the structural integrity of the superior aspect of the mandibular canal.

BACKGROUND: Sparse data can be found regarding the structural integrity of the superior aspect of the mandibular canal. In many cases, the mandibular canal must be carefully evaluated prior to defining patient treatment. METHODS: In this case report, a 54-year-old patient presented with a periapical infection involving the mesial root of the mandibular right second molar (#31). Radiographic evaluation revealed that the periapical lesion extended from the apex of the tooth to the superior aspect of the mandibular canal. Upon surgical removal of the tooth, an apical communication between the extraction socket and mandibular nerve was located. A guided bone regeneration procedure was performed to protect the nerve from subsequent damage and to prepare the site for future implant placement. Implants were placed in the area approximately 5 months following the regenerative procedure. RESULTS: After implant placement, the patient experienced normal function and no mandibular symptomatology. Implants have been in function for the past 4 years. CONCLUSIONS: Many factors, both pathologic and developmental, can lead to a discontinuity of the superior aspect of the mandibular canal. Normally, a thin cortical plate of bone protects the nerve. When a lack of structural integrity of the canal roof is discovered, enucleation of a periapical infection or subsequent implant placement can lead to potential disruption of the nerve. Limited information is available regarding the integrity of this protective cover. This case report underscores the importance of proper clinical diagnosis before implant placement in the posterior mandible.

Barium swallows after free jejunal transfer: should they be performed routinely?

Fistula formation after free jejunal transfer for pharyngoesophageal reconstruction is a serious complication with potentially critical consequences. Barium swallow is used postoperatively to check for anastomotic competence before feeding but has been unreliable as a predictor of leak at our institution. The objective of this study was to evaluate the role of routine postoperative barium swallow in 41 consecutive jejunal transfers. Thirty-nine patients who underwent 41 consecutive free jejunal transfers had a routine barium swallow performed between postoperative days 12 and 17. Radiologic findings and clinical outcome were evaluated and correlated. All barium swallows were reviewed by a single experienced radiologist in a blinded fashion. One total and one partial flap failure necessitated a second free jejunal transfer. Pharyngocutaneous fistulae developed after nine free jejunal transfers, of which the barium swallow was normal in four (44 percent) and showed a leak in five (56 percent). In the 32 free jejunal transfers with no clinical leaks, 6 (19 percent) had radiologic leakage of contrast. Thus, barium swallow was normal in 30 patients and showed leakage in 11 patients. Normal barium swallow correlated with uncomplicated clinical course in 26 of 30 cases. In the remaining four cases (13 percent), however, a delayed fistula developed, which was secondary to flap necrosis in one case (negative predictive value 87 percent). On the other hand, radiologic leaks corroborated clinical fistula in 5 of 11 cases (45 percent), whereas no fistula developed in 6 cases (positive predictive value 46 percent). Of the five patients with clinical fistulae, four had early leaks (within 1 week), and the barium swallow did not provide additional information. The fifth patient developed a delayed leak 2 weeks after the barium swallow. Review of these barium swallows at the time of this study reversed the initial report of leakage in three patients, improving the predictive value to 63 percent. These patients had an uncomplicated clinical course. The positive predictive value of clinical assessment alone was 63 percent. We conclude that barium studies following free jejunal transfers can be difficult to interpret, but an experienced radiologist can improve their accuracy. A normal barium swallow, however, does not ensure an uneventful clinical course. Similarly, radiologic leaks do not imply a clinical complication of fistula. Clinical judgment should therefore be exercised in initiating oral intake after free jejunal transfer. Barium swallow should be used only as an adjunct to aid in patient management.

[Conservative treatment of a case of periapical lesion with complications. Report of a case and calcium hydroxide therapy]. / Szövödményes periapicalis elváltozás konzervatív kezelése. Egy eset kapcsán a kalcium-hidroxidról.

A case and treatment of extraoral fistula on the chin-caused by necrotic pulp of lower left canine--is being presented. In this case an endodontic origin should always be considered from the aspect of differential diagnosis. Nonsurgical endodontic therapy, sometimes complimented by surgery, or extraction are the treatment modalities of these cases. For the treatment calcium hydroxide powder mixed with chlorhexidin gluckonat (0.1%) was used. Usage of calcium hydroxide paste was leaded to rapid and successful healing of extraoral lesions communicating with necrotic tooth.