Radiological analysis of maxillary artery relationships to key bony landmarks in maxillofacial surgery.

The maxillary artery (MA) is a key structure at risk of injury in numerous oral and maxillofacial surgical (OMS) procedures. Knowledge of safe distances from this vessel to surgically familiar bony landmarks could improve patient safety and prevent catastrophic haemorrhage. Distances between the MA and bony landmarks on the maxilla and mandible were measured using CT angiograms on 100 patients (200 facial halves). The vertical height of the pterygomaxillary junction (PMJ) was mean (SD) measurement of 16 (3) mm. The MA enters the pterygomaxillary fissure (PMF) a mean (SD) distance of 29 (3) mm from the most inferior point of the PMJ. The mean (SD) shortest distance between the MA and medial surface of the mandible was 2 (2) mm (with the vessel directly contacting the mandible in 17% of cases). The branchpoint (bifurcation of the superficial temporal artery (STA) and MA) was directly in contact with the mandible in 5% of cases. The mean (SD) distances between this bifurcation point and the medial pole of the condyle were 20 (5) mm and 22 (5) mm, respectively. A horizontal plane through the sigmoid notch perpendicular to the posterior border of the mandible is a good approximation of the trajectory of the MA. The branchpoint is usually within 5 mm of this line and inferior in 70% of cases. Surgeons should take note that both the branchpoint and the MA contact the surface of the mandible in a significant number of cases.

Mandibular fractures - what a difference 30 years has made.

This single-centre retrospective study aimed to characterise the epidemiology, management, and outcomes of mandibular trauma presenting to the same tertiary trauma centre 30 years apart, including key paradigm shifts in management and techniques. A total of 393 patients presenting with 665 mandibular fractures were managed by the Oral and Maxillofacial Surgery department at The Royal Melbourne Hospital (RMH), Australia, between 2011 and 2016. Data from a previous RMH paper of 205 patients presenting with 376 mandibular fractures between January 1985 and April 1990 were compared. Results showed an increase in presentations (205 to 393 patients) with an increase in the incidence of mandibular trauma (p = 0.0001), females (12% to 14%), and mean age (29 to 31.1) years. Young males remained the dominant cohort (86%) and interpersonal violence (IPV) the most common aetiology (46% to 43%). Mandibular fractures remained commonly associated with other systemic injuries (49% to 42%), occurring most frequently on the left (49%), and at the angle (29.8%), with most occurring at two sites (53%). Significant paradigm shifts in the management of mandibular trauma saw a reduced need for intermaxillary fixation (76% to 30%, p = 0.0001), increased use of extraoral approaches to the fracture, and the use of semi-rigid internal fixation along ideal lines of osteosynthesis (29% to 87%, p = 0.0001). This demonstrated decreased complications including malocclusion, non-union and delayed union, and permanent nerve injury. There was no significant change in infection, dehiscence rates, and temporary nerve damage.

Non-smoking, non-drinking elderly females, a 5 year follow-up of a clinically distinct cohort of oral squamous cell carcinoma patients.

To examine differences in survival and clinical outcomes of elderly patients without traditional risk factors presenting with oral squamous cell carcinoma. Retrospective review of 287 consecutive patients divided into 2 treatment period cohorts treated for oral SCC between the 1st Jan 2007 and 31st Dec 2012. Patients were classified as either smoker-drinkers (SD) or non-smoking, non-drinking (NSND). Only patients with oral sub-site primaries according to ICD-10 were included. Carcinomas of the lip, tonsil, base of tongue and oro-pharyngeal subsites were excluded. Of the study population (N = 287), 24.4% were NSND and 9.75% were NSND elderly (older than 70 years) females. >50% of tumours arose from the oral tongue in NSND patients (p = 0.022) and there was a higher rate of recurrent and persistent disease (42.9% vs 27.6%, p = 0.005). Disease specific survival at 5 years was significantly reduced when NSND elderly females were compared to all other patients (p < 0.001) as well as age matched controls (p = 0.006). This effect was verified independently in each cohort.The results of this study suggest that NSND elderly females are a distinct patient population with poorer disease specific survival outcomes.

Predicting the Presence of Oral Squamous Cell Carcinoma Using Commonly Dysregulated MicroRNA in Oral Swirls.

Oral swirls are a noninvasive, rapidly collected source of salivary microRNA (miRNA) potentially useful in the early detection of disease states, particularly oral squamous cell carcinoma (OSCC). The aim of this study was to predict the presence of OSCC using a panel of OSCC-related dysregulated miRNA found in oral swirls, identified jointly in data from formalin-fixed paraffin-embedded (FFPE) and fresh-frozen specimens. Next-generation sequencing (NGS) was used to determine miRNA fold changes in FFPE OSCC specimens relative to histologically normal epithelium. These data were placed with NGS of fresh-frozen tissue data of The Cancer Genome Atlas database to select a panel of commonly dysregulated miRNA. This panel was then analyzed by RT-qPCR in RNA extracted from oral swirls collected from 30 patients with OSCC and 30 controls. Upregulation of miR-31 and miR-21 and downregulation of miR-99a, let-7c, miR-125b, and miR-100 were found between OSCC and controls in both FFPE and fresh-frozen samples. These miRNAs were studied in a training set of 15 OSCC versus 15 control oral swirls to develop a dysregulation score [AUC, 0.95; 95% confidence interval (CI), 0.88-1.03] and classification tree. A test cohort of 15 OSCC versus 15 control oral swirls yielded a dysregulation score AUC of 0.86 (95% CI, 0.79-1.00) with the classification tree identifying 100% (15/15) of OSCC and 67% (10/15) of controls. This study debuts the use of OSCC-associated miRNA, commonly dysregulated in both FFPE and frozen specimens, in oral swirls to indicate the presence of OSCC with high accuracy. Cancer Prev Res; 11(8); 491-502. ©2018 AACR.

Bilateral Distraction Osteogenesis of Vascularized Iliac Crest Free Flaps Used in Mandibular Reconstruction.

Vascularized free flaps have become the gold standard in reconstructing large segmental mandibular defects; however, even when bony union and soft-tissue coverage is achieved, insufficient bone stock and altered facial contour can create functional and cosmetic problems for the patient. There have been limited case reports on the use of secondary distraction osteogenesis to address these issues. The authors report a case of bilateral mandibular distraction of deep circumflex iliac artery free flaps, used for mandibular reconstruction after total mandibulectomy for treatment of osteosarcoma. Performed for reasons of retrognathia and facilitation of dental prosthetic rehabilitation, this is the first case of bilateral horizontal distraction osteogenesis of deep circumflex iliac artery free flaps reported in the literature.

Current concepts in midface fracture management.

PURPOSE OF REVIEW: Management of midface trauma is complex and challenging and requires a clear understanding of the facial buttress system, subunit anatomy and inter-relationships. Too often clinicians attempt surgical repair without adequate knowledge of the common complications associated with poor reduction and improper sequencing of fracture repair. This review outlines a working approach to the identification and management of such injuries, and the definitive management of common injury patterns. RECENT FINDINGS: Midface trauma, with or without life-threatening and sight-threatening complications, may arise following isolated injury, or be associated with significant injuries elsewhere. Assessment needs to be both systematic and repeated, with the establishment of clearly stated priorities in overall care. SUMMARY: Accurate and precise relocation of bony subunits and resuspension of soft tissues is vital in achieving acceptable functional and aesthetic outcomes.

Survival Outcomes of Mucosal Melanoma in the Head and Neck: Case Series and Review of Current Treatment Guidelines.

PURPOSE: Malignant mucosal melanoma of the head and neck (MMHN) is an aggressive and rare neoplasm with poor long-term outcomes. The aim of this study is to evaluate the outcomes of patients treated by a single-institution head and neck multidisciplinary team. MATERIALS AND METHODS: In this retrospective case series, all MMHN cases treated at the Royal Melbourne Hospital from 1990-2015 were retrospectively reviewed. Patient demographic characteristics (eg, age), treatment offered, pathology, and outcomes were collected, tabulated, and correlated with outcomes. Survival outcomes were calculated by the Kaplan-Meier method. Comparison was made between oral and sinonasal melanomas. RESULTS: A total of 16 cases were identified. Two were excluded because of inaccessible data. Of the 14 remaining cases, 8 were sinonasal melanomas and 6 were oral cavity melanomas. Sinonasal tumor patients presented with epistaxis or visual impairment. Oral melanoma patients presented with pigmented lesions or ulceration. Follow-up ranged from 4 months to 11 years. In 2 patients, locoregional recurrences developed that were successfully re-excised. Six patients died of distant metastases despite clear surgical margins. Two patients with sinonasal melanomas died of extensive local disease with intracranial invasion. One patient died 4 years after diagnosis without disease. There were no failures in the neck. The 2- and 5-year overall survival rates were 63.3% and 31.7%, respectively, by the Kaplan-Meier method. The difference in survival between oral and sinonasal melanomas was not statistically significant. CONCLUSIONS: Despite clear surgical margins, MMHN has a poor prognosis and most deaths are due to distant metastases. Systemic therapies such as those used in cutaneous melanoma treatment might be used in the future for MMHN.

Kimura's disease: an uncommon cause of head and neck masses with potentially serious sequelae.

Kimura's disease (KD) typically presents as a mass in the head and neck region in association with eosinophilia and elevated serum IgE. Excisional biopsy is often required in order to obtain an adequate sample for histological diagnosis and exclude malignancy. If suspected, patients should also be investigated for renal involvement as this may complicate KD. Treatment options include surgical excision and medical therapies such as corticosteroids depending on the extent and severity of disease.

Review article: Maxillofacial emergencies: Maxillofacial trauma.

Fractures of the facial skeleton are a common reason for patients to present to EDs and general medical practice in Australia. Trauma to the maxillofacial region can lead to airway obstruction, intracranial injuries, loss of vision or long term cosmetic and functional deficits. This article focuses on the emergency assessment, triage and non-specialist management of traumatic injuries of the orbit and facial skeleton.

Orbitomaxillary mass after repair of the orbital floor.

A 48-year-old man presented with an orbitomaxillary mass 31 years after repair of the orbital floor. He gave a history of progressive diplopia and paraesthesiae of the right infraorbital nerve. He also noted improvement in his long-standing post-traumatic enophthalmos. Imaging showed a large orbitomaxillary cystic mass, which was thought to be secondary to a silicone implant. The implant and the cystic mass were removed, and the orbital floor was reconstructed with titanium mesh. Histological examination confirmed an inclusion cyst. Maxillary antral lesions can present with symptoms such as sinusitis, paraesthesiae, diplopia, and orofacial pain, and they may arise from the lining of the sinus, or from surrounding structures such as the orbit, nose, or maxilla. This was a late complication of silicone elastomeric implants, and there are alternative treatments for defects of the orbital floor.

Review article: Maxillofacial emergencies: oral pain and odontogenic infections.

Oral pain and odontogenic infections are common reasons for patients to present to EDs and general medical practice in Australia. Although most odontogenic infections can be managed on an outpatient basis, because of their proximity to the airway, infections in this region can be life threatening, requiring urgent surgical intervention and ICU management. This article focuses on the emergency assessment, triage and non-specialist management of oral pain and odontogenic infections.

Review article: Maxillofacial emergencies: dentoalveolar and temporomandibular joint trauma.

Dentoalveolar trauma and dislocations of the temporomandibular joint are common reasons for patients to present to EDs in Australia. The majority of medical practitioners receive very little formal training in the management of these injuries and might not have ready access to dental services out of hours for advice. This article focuses on the emergency assessment, triage and non-specialist management of dentoalveolar trauma and injuries to the temporomandibular joint.

Infratemporal inflammatory myofibroblastic tumour with orbital extension.

Inflammatory myofibroblastic tumour (IMT) is a rare distinctive neoplasm of intermediate biological potential with a predilection for the abdominopelvic region and lung of children and young adults. It is histologically composed of spindle cells (myofibroblasts) in a myxoid to collagenous stroma with a prominent inflammatory infiltrate composed primarily of plasma cells and lymphocytes. Its pathogenesis is controversial. Arising most commonly in the lungs, only two cases of histopathologically confirmed IMT originating from the infratemporal and pterygopalatine fossae have been documented in the literature. Neither had orbital involvement. We now report the first case of IMT originating from the infratemporal fossa with orbital extension in a previously well 31-year-old woman. The patient presented with a 5-month history of intermittent right-sided headaches, progressive trismus and right lower lid swelling. She then developed right proptosis, diplopia and paraesthesia in the ophthalmic and maxillary divisions of her trigeminal nerve. Magnetic resonance imaging showed a soft tissue mass occupying most of the right infratemporal fossa with extension into pterygopalatine fossa and orbit. Provisional diagnosis from an open biopsy was nodular fasciitis. She underwent surgical debulking of the infratemporal fossa and lateral orbit through a coronal and trans-oral approach with trans-zygomatic access via total zygomatic osteotomy. Review of intraoperative specimens revised the diagnosis to IMT. Further management included systemic corticosteroids and adjuvant radiotherapy.

Changing patterns of hospital length of stay after orthognathic surgery.

PURPOSE: The purpose of this study was to estimate the hospital length of stay (LOS) and identify factors associated with LOS in orthognathic surgery patients. MATERIALS AND METHODS: Using a retrospective cohort study design, we enrolled a sample composed of patients who underwent orthognathic surgery at Massachusetts General Hospital between January 1994 and July 2006. The primary predictor variables were fixation type (rigid/nonrigid), anesthesia technique (hypotensive/normotensive), and perioperative steroid use (yes/no). The outcome variable was LOS. Descriptive statistics were computed for all variables. Bivariate analyses were used to identify factors associated with duration of LOS with P values less than .15. Multiple regression modeling was used to assess the relationship between the primary predictor variables and LOS. The level of statistical significance was set at P less than .05. RESULTS: The study sample was comprised of 627 subjects (58.5% female) with a mean age of 26.1 +/- 10.2 years. The overall mean LOS was 1.7 +/- 1.2 days. During the study period, LOS decreased from 2.3 to 1.3 days (P < .001). In the adjusted multiple regression model, rigid fixation, procedure type, and length of operation were statistically significantly associated with LOS (P < .05). CONCLUSION: The results of this study indicate that individual variables associated with duration of LOS are complexity of the orthognathic procedure and type of fixation used. In the multiple logistic regression model, LOS decreases significantly when rigid fixation, hypotensive anesthesia, and perioperative steroids are used in combination.

Basic fibroblast growth factor (bFGF) in saliva and oral mucosa in patients with oral lichen planus: preliminary observations.

OBJECTIVE: Basic fibroblast growth factor (bFGF) is important for wound healing and tissue repair. This study measures the concentration of bFGF in oral lichen planus (OLP) affected mucosa and in the saliva of patients with OLP. STUDY DESIGN: Samples of saliva, OLP-affected mucosa, and clinically healthy mucosa were obtained from 11 patients. Control samples were obtained from healthy volunteers. The bFGF content of tissue samples and saliva was examined by ELISA. RESULTS: The mean bFGF concentration in saliva from OLP patients was 5.9 pg/mL, SD 2.9, compared with 0.3 pg/mL, SD 0.3, in the control group, (P>.01). The bFGF content in the OLP tissue was 90.6 microg/mg protein, SD 39.5, in clinically normal mucosa from OLP individuals it was 46.2 microg/mg protein, SD 12.0 (P=.02), and in the control group 46.2 microg/mg protein, SD 11.5 (P>.01). CONCLUSION: OLP-affected mucosa contained significant more bFGF than nonaffected mucosa in OLP and healthy mucosa in control group. There is no difference between nonaffected mucosa in OLP and control group. Saliva in OLP patients contained more bFGF than saliva in control patients.