Clinical investigation of patients with jaw deformity with comorbidities.

BACKGROUND: With improvements in the safety and stability of surgeries, the number of orthognathic surgeries is increasing. Most patients who undergo orthognathic surgeries are younger, and the number of orthognathic surgeries for patients with comorbidities is also increasing. We report a survey and clinical investigation of patients with comorbidities who underwent orthognathic surgeries at our department to improve the safety of orthognathic surgery. RESULTS: The participants included 296 men and 712 women, with a mean age of 28 years (13-19 years, n=144; 20-29 years, n=483; 30-39 years, n=236; 40-49 years, n=102; 50-59 years, n=39; ≥60 years, n=4). In total, 347 patients underwent one-stage Le Fort type I osteotomy and sagittal split ramus osteotomy (SSRO), 243 underwent SSRO, 287 underwent plate removal, 126 underwent genioplasty and plate removal, and five underwent other surgeries. In total, 529 patients had comorbidities (52%), including allergic diseases (n=220, 33%), respiratory diseases (n=107, 16%), neurologic and psychiatric diseases (n=69, 10%), gynecologic diseases (n=28, 4%), hematologic diseases (n=27, 4%), cardiovascular diseases (n=24, 4%), digestive diseases (n=22, 3%), metabolic and endocrine diseases (n=18, 3%), spinal diseases (n=11, 2%), ophthalmologic diseases (n=11, 2%), renal and urological diseases (n=9, 1%), and other diseases (n=117, 18%). Among the patients with comorbidities, 11 with hemorrhagic diatheses (hemophilia and von Willebrand disease), arrhythmia (atrioventricular block), psychiatric disease (adjustment disorder), and metabolic disease (diabetes) required cautious perioperative management. The patient with hemophilia was managed with regular low-dose recombinant factor VIII replacement therapy, and the patient with type I diabetes mellitus was administered continuous insulin infusion and sliding-scale insulin therapy; both patients had an uneventful course. CONCLUSIONS: The study findings suggest that with the increase in orthognathic surgeries, oral and maxillofacial surgeons should adequately manage cases requiring cautious perioperative control and highlight the importance of preoperative screening. Despite the well-established safety and postoperative stability of orthognathic surgeries, oral surgeons should adopt appropriate additional preventive measures for patients with comorbidities.

A clinico-statistical study of factors associated with intraoperative bleeding in orthognathic surgery.

BACKGROUND: Excessive bleeding is a major intraoperative risk associated with orthognathic surgery. This study aimed to investigate the factors involved in massive bleeding during orthognathic surgeries so that safe surgeries can be performed. Patients (n=213) diagnosed with jaw deformities and treated with bimaxillary orthognathic surgery (Le Fort I osteotomy and bilateral sagittal split ramus osteotomy) in the Department of Oral and Maxillofacial Surgery at the Suidobashi Hospital, Tokyo Dental College between January 2014 and December 2016 were included. Using the patients' medical and operative records, the number of cases according to sex, age at the time of surgery, body mass index (BMI), circulating blood volume, diagnosis of maxillary deformity, direction of maxillary movement, operative duration, incidence of bad split, injury of nasal mucosa, and blood type were analyzed. RESULTS: The results revealed that BMI, circulating blood volume, nasal mucosal injury, and operative time were associated with the risk of intraoperative massive bleeding in orthognathic surgeries. Chi-square tests and binomial logistic regression analyses showed significant differences in BMI, circulating blood volume, direction of maxillary movement, operative duration, and injury to the nasal mucosa. Operative duration emerged as the most important risk factor. Furthermore, a >4-mm upward migration of the posterior nasal spine predicted the risk of massive bleeding in orthognathic surgery. CONCLUSIONS: The upward movement of the maxilla should be recognized during the preoperative planning stage as a risk factor for intraoperative bleeding, and avoiding damage to the nasal mucosa should be considered a requirement for surgeons to prevent massive bleeding during surgery.

Countermeasure and opportunistic screening systems for oral cancer.

OBJECTIVES: Tokyo Dental College started oral cancer screening in cooperation with a local dental association in 1992. Reveal the usefulness of Countermeasure and Opportunistic Screening Systems for Oral Cancer. The actual results of countermeasure and opportunistic oral cancer screening systems are reported. MATERIALS AND METHODS: Countermeasure screening for the public was performed in each region, and opportunistic screening was performed in a general dental clinic of a cooperating physician. RESULTS: In countermeasure screening, 19,721 persons were checked from 1992 to 2018; the gender ratio was 1:3. The close examination rate was 4.45%. The detection rates of oral cancer and oral potentially malignant disorders were 0.13% and 1.85%, respectively. In opportunistic screening, 29,912 persons were checked from 2006 to 2018; the gender ratio was 2:3. The close examination rate was 2.33%. The detection rates of oral cancer and oral potentially malignant disorders were 0.08% and 2.15%, respectively. The close examination rate was significantly lower in opportunistic screening than in countermeasure screening. The oral cancer detection rates and the positive predictive value for cancer were equivalent. In addition, the detection rate of oral potentially malignant disorders was significantly higher in opportunistic screening than in countermeasure screening. CONCLUSION: Oral cancer detection rates were equivalent between countermeasure and opportunistic screenings, and opportunistic screening were more effective on number of participants and the close examination rate, and the detection rate of oral potentially malignant disorders.

Metabolomic analysis of the saliva of Japanese patients with oral squamous cell carcinoma.

The aim of the present study was to characterize the metabolic systems in Japanese patients with oral squamous cell carcinoma (OSCC) using capillary electrophoresis-mass spectrometry (CE-MS) metabolome analysis of saliva samples. A previous study showed variations among ethnicities and tumor sites in the saliva metabolome of patients with OSCC using CE-MS. In the present study, saliva was obtained from 22 Japanese patients with OSCC and from 21 healthy controls who visited the Department of Dentistry, Oral and Maxillofacial Surgery, Tokyo Dental Collage Ichikawa General Hospital, Tokyo, Japan, and all samples were subject to comprehensive quantitative metabolome analysis using CE-MS. A total of 499 metabolites were detected as CE-MS peaks in the saliva tested from the two groups. A total of 25 metabolites were revealed as potential markers to discriminate between patients with OSCC and healthy controls: Choline, p-hydroxyphenylacetic acid, and 2-hydroxy-4-methylvaleric acid (P<0.001); valine, 3-phenyllactic acid, leucine, hexanoic acid, octanoic acid, terephthalic acid, γ-butyrobetaine, and 3-(4-hydroxyphenyl)propionic acid (P<0.01); and isoleucine, tryptophan, 3-phenylpropionic acid, 2-hydroxyvaleric acid, butyric acid, cadaverine, 2-oxoisovaleric acid, N6,N6,N6-trimethyllysine, taurine, glycolic acid, 3-hydroxybutyric acid, heptanoic acid, alanine, and urea (P<0.05, according to the Wilcoxon rank sum test). A previous study by Sugimoto and co-workers detected 24 discriminatory metabolites, 7 of which (taurine, valine, leucine, isoleucine, choline, cadaverine, and tryptophan) were also detected in the present study. In the present study, however, choline, metabolites in the branched chain amino acids (BCAA) cycle, urea, and 3-hydroxybutyric acid were also characterized. Choline and metabolites of the BCAA cycle have previously been reported in OSCC using metabolome analysis. To the best of our knowledge, no previous reports have identified urea and 3-hydroxybuyric acid in the metabolome of patients with OSCC. These findings suggest the usefulness of metabolites as salivary biomarkers for Japanese patients with OSCC. Further studies using larger patient cohorts should be conducted to validate these results.

A Case of Infratemporal Fossa Abscess with Signs of Chronic Maxillary Osteomyelitis.

The infratemporal fossa is bordered superiorly by the infratemporal surface of the greater wing of the sphenoid bone and part of the temporal bone; medially by the lateral plate of the pterygoid process of the sphenoid bone; and anteriorly by the posterior surface of the maxilla. As it is completely surrounded by bone, it is frequently difficult to determine whether an abscess is present by direct visual observation or palpation alone. We report an extremely rare case of an infratemporal fossa abscess arising from chronic maxillary osteomyelitis developing after extraction of a maxillary molar. Despite drainage during initial oral anti-inflammatory treatment, pus continued to drain from the wound over a long period of time. This drainage ended when the eroded bone of the maxillary tuberosity on the affected side was curetted in a secondary procedure. The harvested bone tissue exhibited histological findings of chronic osteomyelitis. This suggests that the route of infection involved acute transformation of maxillary osteomyelitis by odontogenic infection advancing posteriorly and superiorly.

A case of mucoepidermoid carcinoma associated with maxillary cyst.

We report a case of a mucoepidermoid carcinoma associated with a maxillary cyst. The patient was an 18-year-old man presenting with the chief complaint of left buccal swelling. The left maxillary third molar was semi-impacted in the direction of the crown on the buccal side. Orthopantomography revealed a cystic radiolucency extending over a wide area, ranging from the left maxilla to the maxillary sinus and nasal cavity. Computed tomography revealed a multilocular lesion surrounded by a thin shell of bone. Biopsy findings revealed a cystic lesion, but the cause could not be identified preoperatively. The cystic lesion was resected under general anesthesia. The lesion was multilocular and surrounded by a bone shell, and had expanded into the maxillary sinus. At the same time, indurated soft tissue adhering strongly to the palatine bone on the inferior palatine side of the lesion was resected. Histopathological examination showed a cystic lesion and mucoepidermoid carcinoma. An additional resection was planned and the maxilla partially resected. Mucoepidermoid carcinomas usually occur in the parotid and minor salivary glands, but in rare cases appear in the center of a jaw bone, almost always in the mandible. In the present case, the carcinoma was associated with a cystic lesion believed to have developed from maxillary bone and involved an impacted tooth adjacent to the tumor. This suggested a central mucoepidermoid carcinoma in the maxillary cyst. Postoperatively, the missing teeth have been replaced with a denture and the course has been good, with no recurrences or metastases identified.

A case of Sotos syndrome treated with distraction osteogenesis in maxilla and mandible.

Sotos syndrome is inherited in an autosomal-dominant manner and is characterized by increased birth weight, excessive growth, advanced bone age, and distinctive facial features, including dolichocephaly, hypertelorism, and a prominent mandible. We treated a jaw deformity due to Sotos syndrome consisting of malocclusion due to a narrow maxillary dental arch and mandibular retrusion from hypoplasia of the rami. The patient was a 17-year-old man. Malocclusion due to a narrow maxillary dental arch and mandibular retrusion was diagnosed. Rapid maxillary expansion with Lines corticotomy and mandibular advancement with distraction osteogenesis were performed. The maxilla was expanded laterally a total of 3 mm and the mandible prolonged 12 mm in the posterior area of the mandibular body. Subsequently, orthodontic treatment was continued. At present, 5 years after surgery, occlusion remains good and stable.

Systemic Inflammatory Response Syndrome and postoperative complications after orthognathic surgery.

Symptoms of Systemic Inflammatory Response Syndrome (SIRS) presenting immediately after surgery have lately been regarded as potential warnings of impending postoperative complications and multiple organ failure. Reports discussing the relationship between operative stress and SIRS are found in the field of digestive surgery, but not in that of oral surgery. Sixty-five patients with jaw deformity who had undergone maxillary and mandibular orthognathic surgery (Le Fort I osteotomy and sagittal splitting ramus osteotomy) between September 2003 and October 2006 were involved in this study. A search based on the SIRS diagnostic criteria resulted in assignment of 33 cases to the SIRS group and 32 cases to the non-SIRS group. Postoperative complications occurred in 27.3% of the SIRS group and 0.0% of the non-SIRS group (p<0.01). In four cases, a postoperative fluctuation in IL-6 level evaluated. These results suggest the importance of careful management of postoperative SIRS patients in preventing complications.

Course of fracture line in sagittal splitting of human mandible.

We performed sagittal splitting osteotomy using fresh, unfixed cadavers. Observation was carried out macroscopically and with light microscopy and 3-dimensionally reconstructed images. The aim of this study was to clarify the relationship between the fracture line and the Haversian canal and Haversian lamellae. Macroscopic observation revealed that the fracture line run through the mandibular angle from the inferior rim of the mandibular ramus towards the posterior rim, passing almost through the center of the ridgeline. Histological observation showed that the fracture line tended to run along the curve of the lamellar structure. The incidence of the fracture line running along the lamellar structure of the Haversian lamellae was approximately 65% (21 cases), and the incidence of the fracture line also cutting across the Haversian canal without passing along the lamellar structure of the Haversian lamellae was approximately 35% (11 cases). Observation of 3-dimensional reconstruction images revealed that the section of Haversian canal near the mandibular angle essentially runs from the mandibular head to the inferior rim of the mandible, and that the fracture plane ran similarly. The direction of an impact-associated bone fracture line is influenced by the structures that constitute the lamellar bone such as Haversian canals, Haversian lamellae and interstitial lamellae, with fracture lines tending to run through those parts of the bone that have a low physical bond strength. This suggests that the ideal direction of action of the bone chisel in sagittal splitting surgery is the one in which no resistance to the path of the Haversian canal is encountered.

Model surgery technique for Le Fort I osteotomy--alteration in occlusal plane associated with upward transposition of posterior maxilla.

It is difficult to translate analytical values into accurate model surgery by traditional methods, especially when moving the posterior maxilla. This is because cephalometric radiographic analysis generated information on movement of the posterior nasal spine (PNS) can not be recreated in model surgery. Therefore, we propose a method that accurately reflects such analysis and simulation of movement using Quick Ceph 2000 (Orthodontic Processing Corporation, USA). This will allow the enrichment of model surgery prior to actual surgery in cases where upward movement of the posterior maxilla is involved. All patients who participated in this study had skeletal mandibular prognathism characterized by a small occlusal plane angle in respect to the S-N plane. Cephalometric radiographs were taken and analyzed with the Quick Ceph 2000. Pre- and post-surgical evaluations were performed using Sassouni arc analysis and Ricketts analysis. Prior to transposition, we then prepared an anterior occlusal bite record on a model mounted on an articulator. This bite was then used as a reference when the molar parts were to be transposed upwards. The use of a occlusal bite permitted an accurate translation of the preoperative computer simulation into model surgery, thus facilitating favorable surgical results.

[A case of primary lung cancer in a young female with tongue cancer].

We describe a case of lung tumor in a 33-year-old woman with tongue cancer. She had noticed a painful sensation in her tongue in April 2000. The results of a physical examination showed a 22 x 11 mm ulcerated lesion on the right side of her tongue. A biopsy specimen showed a moderately differentiated squamous cell carcinoma. A preoperative chest radiograph showed no evidence of pulmonary metastasis. No neck lymphadenopathy was found. The tongue cancer was resected in September 2000, and the pathological stage was T2 N0 M0. A solitary pulmonary lesion appeared 8 months after the surgery. A Histological examination of a transbronchial lung biopsy specimen showed a moderately differentiated squamous cell carcinoma. It was difficult to distinguish histopathologically or immunohistochemically between a second primary tumor and a metastasis, but the pulmonary lesion was considered to be a second primary tumor on the basis of a single endobronchial lesion that appeared after the T2 tongue cancer with no regional recurrence or cervical lymphadenopathy. Treatment with chemotherapy and irradiation was not effective and the patient died 3 months after the diagnosis of lung cancer.