Aneurysmal bone cyst of the tuberculum articulare of the temporomandibular joint: a case report.

A case is presented of a 14-year-old boy with aneurysmal bone cyst of the tuberculum articulare of the temporomandibular joint (TMJ). This disease rarely involves the skull, and involvement of temporal bone is even more rare. To our knowledge, only 22 cases have been reported in the literature. This is the first case of aneurysmal bone cyst of the tuberculum articulare of the TMJ described in the literature.

Evaluation of secondary functional cheilorhinoplasty during growth of cleft patients with residual lip and nasal deformities.

PURPOSE: The aim of the study was to evaluate the clinical outcomes of secondary functional cheilorhinoplasty of residual lip and nasal deformities caused by muscular deficiency in cleft patients. PATIENTS AND METHODS: During a 4-year period, 31 patients underwent cheilorhinoplasty, including complete reopening of the cleft borders and differentiated mimic muscle reorientation. In 21 patients, remarkable residual clefts of the anterior palate were also closed. Simultaneous alveolar bone grafting was performed in 15 patients. The minimum follow-up was 1 year. Cosmetic features evaluated were spontaneous facial appearance and changes in position of the nasal floor and the philtrum. The width of the alar base was measured. For functional outcomes, deficiency during mimic movements was evaluated, using standardized photographs taken preoperatively and postoperatively. The final results, judged according to defined criteria with several clinical factors, were compared. RESULTS: Cosmetic and functional improvement was achieved in all patients. In young patients (aged 4 to 9 years), the improvements were noteworthy. There were no differences in outcomes between the groups with and without simultaneous grafting, except for unilateral cases with minor muscular deficiency, in whom bone grafting before cheilorhinoplasty led to better results. CONCLUSION: In cases of major muscular deficiency, early cheilorhinoplasty should be performed at age 7 years, without waiting for the usual timing of bone grafting. In minor and moderate cases, the operation can ideally be done in combination with bone grafting.

Efficiency of arthroscopic lysis and lavage for internal derangement of the temporomandibular joint correlated with Wilkes classification.

OBJECTIVES: To compare the outcome of arthroscopic lysis and lavage of TMJ with internal derangement of Wilkes stages II, III, IV, and V. STUDY DESIGN: Arthroscopic lysis and lavage was performed in 45 TMJ of 39 patients with internal derangement. The cases were divided into 4 groups corresponding to Wilkes stages II, III, IV, and V. Two parameters were compared pre- and postoperatively: pain and mouth opening. Statistical significance was determined using the chi(2) test. RESULTS: Overall success rate was 86.7% (Wilkes stage II 90.9%, Wilkes stage III 92.3%, Wilkes stage IV 84.6%, Wilkes stage V 75%). There were no statistically significant differences between the success rates for Wilkes stages II, III, IV, and V. CONCLUSION: Arthroscopic lysis and lavage should be performed as a standard operation for internal derangement of the TMJ after failure of conservative treatment in all Wilkes stages.

Fibula free flap reconstruction of the mandible in cancer patients: evaluation of a combined surgical and prosthodontic treatment concept.

The final goal of mandibular reconstruction following ablative surgery for oral cancer is often considered to be dental implant-supported oral rehabilitation, for which bone grafts should ideally be placed in a suitable position taking subsequent prosthetic restoration into account. The aim of this study was to evaluate the efficacy of a standardized treatment strategy for mandibular reconstruction according to the size of the bony defect and planned subsequent dental prosthetic rehabilitation. Data of 56 patients, who had undergone such a systematic mandibular fibula free flap reconstruction, were retrospectively analyzed. Early complications were observed in 41.5% of the patients but only in those who had been irradiated. Late complications were found in 38.2%. Dental implant survival rate was 92%, and dental prosthetic treatment has been completed in all classes of bony defects with an overall success rate of 42.9%. The main reasons for failure of the complete dental reconstruction were patients' poor cooperation (30.4%) and tumour recurrence (14.3%) followed by surgery-related factors (10.8%) such as implant failure and an unfavourable intermaxillary relationship between the maxilla and the mandible. A comparison of our results with the literature findings revealed no marked differences in the complication rates and implant survival rates. However, a systematic concept for the reconstructive treatment like the method presented here, plays an important role in the successful completion of dental reconstruction. The success rate could still be improved by some technical progress in implant and bone graft positioning.

A 3-year survey of assault-related maxillofacial fractures in central Switzerland.

AIM: The aim of this study was to analyse the character of assault-related facial fractures in central Switzerland and to compare their prevalence with the data presented in similar reports from other countries. MATERIAL: The present study comprised 65 patients with assault-related maxillofacial fractures treated in the Department of Cranio-Maxillofacial Surgery, University Hospital of Bern between 2000 and 2002. METHODS: The mechanism, the causes of the injuries and the location of the fractures were analysed by reviewing emergency and hospital records. Concomitant injuries were also studied. RESULTS: The mean age of the patients was 33 years with the largest group being below 25 years. The male-to-female ratio was 56:9. The most common causes of assault-related injuries were fights, most frequently facial blows, accounting for 92.5% of all patients. Seventy-six per cent of the fractures occurred in the middle and upper facial skeleton with a predominance of 2:1 for the left side. In 39 patients (60%) surgery was necessary, with a mean hospital stay of 3.3 days. Thirty-five patients (54%) had concomitant injuries. Alcohol and drug abuse was found in 15 patients (23%). CONCLUSION: It seems that mostly young men suffer assault-related maxillofacial injuries. A contributing factor to the increased disposition for violence could be alcohol and drug abuse. Therefore, national prevention programmes for alcohol or drug abuse and addiction might have a positive effect on reducing the incidence of assault-related maxillofacial injuries.

Bi-directional distraction osteogenesis of the alveolar bone using an extraosseous device.

OBJECTIVES: In alveolar distraction, the bone segment tends to incline palatally or lingually, making rigid control of the segments difficult. The aim of this study was to evaluate the usefulness of a newly developed bi-directional extraosseous alveolar distractor (Medartis V2-Alveolar distractor) for pre- and perioperative vector management. MATERIAL AND METHODS: Seven patients with segmental alveolar atrophy following traumatic tooth loss were treated using the distraction device. The patients were followed up clinically and radiologically. Preoperatively, the initial vector for distraction was determined using CT by measuring the cross-section of the bone. The morphology of the alveolar bone was also analyzed in relation to the planned implant position. Postoperatively, the rate of osteogenesis was monitored with plane radiographs and CT scan. RESULTS: All cases had bone deficit at the anterior surface of the alveolar ridge, showing a typical inclination of the long axis of the bone. Using the distractor, vertical distraction and positioning of the segments with labial orientation was possible. After a consolidation period of 12 weeks on average, sufficient bone formation for implant installation was radiologically observable. Histologic and histomorphometric analysis of one bone biopsy showed very dense mineralized bone (area fraction=78%) with a multidirectional, complex architecture. Implant-supported prosthetic oral rehabilitation was successfully performed in all cases. CONCLUSION: All complications observed in this study were related to the bone deficiency at the anterior surface of the alveolar process. If the technique can be improved, this type of bi-directional distraction is a promising method for alveolar bone repair.

Relationship between lower wisdom tooth position and cyst development, deep abscess formation and mandibular angle fracture.

AIM: There is an ongoing controversy about indications for prophylactic removal of third molars. The purpose of this retrospective study was to clarify the risk of preservation of lower third molars. MATERIAL AND METHOD: In a 5-year period, 316 patients were registered who had received in-patient treatment for deep abscess formation, cyst formation or mandibular angle fracture in relation to lower third molars. A radiological analysis (panoramic radiographs) was performed to determine whether major pathological changes associated with lower wisdom teeth are related to their position. Third molar positions were studied in this in-patient group and in an out-patient group. The latter consisted of 300 consecutive patients with prophylactically removed impacted third molars without any pathology. The relationship between the positions and the different pathological changes associated with impacted lower wisdom teeth was analysed statistically using a new 'position score'. RESULTS: The study revealed that the highest 'position scores' corresponding to a leading aberrant position correlated significantly with cyst formation. Lower scores corresponding to moderately aberrant or slightly irregular position were found with angle fractures, abscess formation, and in the control group as a whole. CONCLUSION: This study indicates that prophylactic third molar surgery for teeth with high and strongly elevated 'position scores' is appropriate in order to prevent cyst formation or mandibular angle fractures in a population at risk for facial trauma. In addition to other factors, 'position score' data could be useful for development of a model for predicting severe complications related to (removal of) impacted lower wisdom teeth.

Long-term changes of hyoid bone and pharyngeal airway size following advancement of the mandible.

OBJECTIVE: To determine long-term changes in hyoid bone position and pharyngeal airway size after mandibular advancement, including evaluation of the relationship between length of suprahyoidal musculature and skeletal relapse. STUDY DESIGN: A cephalometric follow-up study (12 years) of 15 patients who underwent mandibular advancement surgery. RESULTS: The final position of the hyoid bone was more posterior than it had been preoperatively. Suprahyoidal musculature continuously lengthened from preoperatively to 12 years postoperatively. Total skeletal relapse at B-point and pogonion correlated significantly with postoperative stretch of suprahyoidal musculature. The upper and middle pharyngeal airways were narrower than their preoperative values. CONCLUSIONS: Mandibular changes influence hyoid bone position during the entire postoperative period, whereas stretching of suprahyoidal musculature seems to contribute to skeletal relapse. Mandibular advancement surgery alone possibly does not achieve a stable increase of pharyngeal airway size over a long-term period of 12 years.

The value of computed tomographic scanning in the diagnosis and management of orbital fractures associated with head trauma: a prospective, consecutive study at a level I trauma center.

BACKGROUND: Orbital fractures associated with head trauma are not always easy to diagnose. The real incidence of such fractures is unknown. The aim of this study was to evaluate the usefulness of routine primary computed tomographic (CT) scanning for diagnosis of orbital fractures in head trauma patients. METHODS: Over a 3-year period, 600 consecutive patients admitted with head trauma were examined clinically; these patients then underwent cranial helical CT scanning, irrespective of severity of head injuries and presence or absence of fracture-related symptoms. RESULTS: Orbital fractures were diagnosed on CT scan in 118 cases (19.7%). All patients with symptoms directly related to an orbital fracture had radiologically diagnosed fractures, compared with 58.3% of patients with isolated blepharohematoma and 3.8% of asymptomatic patients. CONCLUSION: CT scan of the orbits is indicated for any head trauma patient who presents either one or more symptoms directly related to an orbital fracture or just isolated blepharohematoma. CT scan of the orbits is not indicated in asymptomatic head trauma patients. Inclusion of the orbits in the scanning is recommendable only if a CT scan is already being obtained for a head injury. Clinical follow-up is important to detect any late-appearing symptoms. Accurate clinical examination still plays a crucial role in the diagnosis of orbital fractures.

Oral rehabilitation after mandibular reconstruction using an osteocutaneous fibula free flap with endosseous implants. Factors affecting the functional outcome in patients with oral cancer.

BACKGROUND: The development of endosseous implants and free vascularized bone grafting has permitted increased possibilities of oromandibular reconstruction in patients with oral cancer. In this study, a concept combining surgical and prosthodontic treatments for mandibular fibula free flap reconstruction after tumor surgery was made based on a classification of bone defects. A follow-up study was performed to evaluate the treatment concept for oral rehabilitation in order to identify possible factors which may influence the functional result. MATERIAL AND METHODS: A follow-up examination included 28 patients who underwent the ablative tumor surgery and mandibular reconstruction during a 4-year period. The follow-up protocol included clinical examination, radiological evaluation, and an interview using a standardized questionnaire. The timing of the study was set to allow for a minimum 2-year follow-up (mean 45 months). RESULTS AND CONCLUSION: At the time of examination, prosthesis-based oral rehabilitation was completed in six patients (21%), and the prosthodontic work was still unfinished in four other patients. The other 18 had no dental prosthetic rehabilitation. Thirteen patients received a total of 37 oral implants, and 23 implants were functionally loaded. No implant loss was recorded. Oral functions such as speech, diet tolerance and oral competence were not directly affected by the presence of dentures. A decisive factor affecting the oral function was the extent of soft-tissue loss. According to the classification described here, the extent of the mandibular defect did not correlate with oral functions. The application of oral implants seemed to be advantageous for the oral rehabilitation of patients who had undergone intraoral resections.