Variation of plate fixation for mandibular advancement with intraoral vertical ramus osteotomy using endoscopically assisted intraoral rigid or semi-rigid internal fixation: Case series study: Postoperative condylar seating control for mandibular advancement.

The purpose of the present study was to evaluate the safety and efficacy associated with mandibular advancement by intraoral vertical ramus osteotomy (IVRO) with endoscopically assisted intraoral rigid or semi-rigid internal fixation. The study sample included all patients who had undergone an mandibular advancement by IVRO procedure with endoscopically assisted intraoral plate fixation from September 2008 to May 2012. An mandibular advancement by IVRO with endoscopically assisted intraoral rigid or semi-rigid internal fixation was used for mandibular advancement. The patients were analyzed prospectively, with more than 2 years of follow-up, and were evaluated in terms of functional results, postoperative complications, and skeletal stability. A total of 14 patients (bilateral, 7 patients with class II; unilateral, 7 patients with asymmetry) were included in the present study. The average degree of mandibular advancement was 5.5 ± 1.9 mm (range, 3-9 mm). Both the occlusal relationship and facial appearance in all patients were significantly improved by the surgical-orthodontic treatment, with no major harmful clinical symptoms. In addition, one-screw semi-rigid fixation could control postoperative passive condylar seating. This study showed that mandibular advancement by IVRO with endoscopically assisted, intraoral semi-rigid internal fixation offers a promising treatment alternative for patients with skeletal class II malocclusion or facial asymmetry.

Combination of Mandibular Constriction and Intraoral Vertical Ramus Osteotomies for a Transverse Jaw Discrepancy.

BACKGROUND: The aim of the present study was to evaluate the treatment of patients developing a transverse jaw width discrepancy who exhibited class III malocclusion and/or facial asymmetry by a combination of mandibular constriction (MC) and intraoral vertical ramus osteotomies (IVROs). SUBJECTS AND METHODS: In a retrospective study, functional results, postoperative complications, and skeletal stability were analyzed for all the patients who had undergone MC and IVRO, with more than 2 years of follow-up. A mandibular midline osteotomy for constriction with lag screw technique and IVROs was used for MC and setback. RESULTS: Sixteen patients were included in the present study. The average degree of MC was 6.34 mm. Both the occlusal relationship and facial appearance in all patients were significantly improved by the surgical orthodontic treatment, with no harmful clinical symptoms. In addition, our original MC using lag screw technique provided the most reliable results in terms of skeletal stability. CONCLUSIONS: This study showed that MC using lag screw technique gives a very stable mandibular width constriction, and the combination of MC and IVROs offers a promising treatment alternative for patients with mandibular prognathism developing a transverse jaw width discrepancy.

Odontogenic carcinoma with dentinoid: a new odontogenic carcinoma.

Dentinoid is an integral part of some odontogenic tumors. This article describes the clinico-pathological features of three cases of odontogenic carcinomas with dentinoid (OCD). A comparison of these with previously reported cases of dentinoid-producing epithelial odontogenic tumors allowed us to identify another six cases that may be considered as examples of OCD. Six cases occurred in the mandible and three in the maxilla, all developing behind the canines. There was no sex predilection (five men and four women; age range 14-61 years, mean 38.1). Pain or discomfort was mentioned in five cases, four of which showed tooth resorption. All cases appeared initially as well-defined radiolucencies, five of which showed variable amounts of calcified material. Recurrences were recorded in three instances, but no evidence of metastasis has been found. Seven cases were composed predominantly or entirely of clear cells, usually with minimal cellular atypia and variable mitotic activity; however, in all cases there was evidence of tumor infiltration into adjacent tissues, including the presence of perineural invasion in two tumors. Those cases in which no reference was made to the presence of clear cells exhibited evident mitotic activity and cellular pleomorphism. The epithelium in OCD does not produce buds or enamel organ-like structures such as those found in ameloblastic fibro-dentinoma and this tumor does not contain a mesenchyme-like connective tissue resembling dental papilla as observed in several mixed odontogenic tumors. Based on the existing data and the present series of cases, OCD appears to represent a distinct entity.

Computer-aided design provisionalization and implant insertion combined with optical scanning of plaster casts and computed tomography data.

The conventional implant prosthesis planning process currently involves confirmation of two-dimensional anatomical findings or the quantity and quality of bones using panoramic X-ray images. The introduction of computed tomography (CT) into the field has enabled the previously impossible confirmation of three-dimensional findings, making implant planning in precise locations possible. However, artifacts caused by the presence of metal prostheses can become problematic and can result in obstacles to diagnosis and implant planning. The most updated version of SimPlant(®) Pro has made it possible to integrate plaster cast images with CT data using optical scanning. Using this function, the obstacles created by metal prostheses are eliminated, facilitating implant planning at the actual intraoral location. Furthermore, a SurgiGuide(®) based on individual patient information can be created on plaster casts, resulting in easier and more precise implant insertion.

Risk of maxillary artery injury during an intraoral vertical ramus osteotomy in Japanese patients is high--is it enough just to avoid damaging the inferior alveolar nerve?

PURPOSE: Since managing a case in which the maxillary artery was injured during intraoral vertical ramus osteotomy (IVRO) with intraoperative transcatheter arterial embolization, we have conducted preoperative vascular computed tomography (CT) evaluations of the maxillary artery course in patients scheduled to undergo mandibular bone osteotomy. The aim of the present study was to describe the anatomy of the maxillary artery in the infratemporal artery in Japanese patients. MATERIALS AND METHODS: The study design was a prospective case series. The study sample included all patients who had undergone IVRO from October 2009 to December 2012. We evaluated the positional relationship between the maxillary artery and the mandible using CT vascular imaging before surgery. The primary outcome variable was the requirement for subperiosteal dissection on the medial surface of the mandible from the perspective of the intersection of the route of the maxillary artery with the IVRO osteotomy line. RESULTS: A total of 156 sides from 78 patients who had undergone mandibular bone osteotomy were included in the present study. The maxillary artery course was positioned directly below the mandibular notch in approximately one half of the cases, necessitating subperiosteal dissection on the medial surface of the mandible. CONCLUSIONS: IVRO is a common surgical procedure that can be safely and easily conducted in conjunction with endoscopy. However, improved maxillary artery damage prevention methods are recommended, such as subperiosteal dissection on the medial surface of the mandible and filling the medial surface of the mandibular ramus with gauze.

Three-dimensional virtual operations can facilitate complicated surgical planning for the treatment of patients with jaw deformities associated with facial asymmetry: a case report.

This article describes a case we experienced in which good postsurgical facial profiles were obtained for a patient with jaw deformities associated with facial asymmetry, by implementing surgical planning with SimPlant OMS. Using this method, we conducted LF1 osteotomy, intraoral vertical ramus osteotomy (IVRO), sagittal split ramus osteotomy (SSRO), mandibular constriction and mandibular border genioplasty. Not only did we obtain a class I occlusal relationship, but the complicated surgery also improved the asymmetry of the frontal view, as well as of the profile view, of the patient. The virtual operation using three-dimensional computed tomography (3D-CT) could be especially useful for the treatment of patients with jaw deformities associated with facial asymmetry.

Clinical approach for mandibular advancement by intraoral vertical ramus osteotomy with endoscopically assisted intraoral fixation of an L-shaped compact lock plate.

Intraoral vertical ramus osteotomy (IVRO) is widely used as a surgical corrective method to treat patients with skeletal class III malocclusion with mandibular setback. However, the conventional surgical method applied for mandibular advancement has induced such complications as condylar luxation caused by the instability of the placement of the proximal segment. To avoid this complication, it has been necessary to use the fixation of the proximal and distal segments with an L-shaped compact lock plate via an extraoral approach. This has made surgeons hesitate to propose this osteotomy for patients with skeletal class II malocclusions. We herein report a new surgical approach for the IVRO for mandibular corrective advancement with endoscopically assisted fixation of an L-shaped compact lock plate and good positioning of the condyle via an intraoral approach.The osteotomized mandibular segments were fixed with an L-shaped compact lock plate using right-angled burs and right-angled screwdrivers. Seven patients were included in this study. The average degree of mandibular advancement was 6.1 mm (range, 3.5-9 mm). Our results suggest that mandibular advancement by IVRO with endoscopically assisted intraoral fixation of an L-shaped compact lock plate in patients with skeletal class II malocclusion might be useful to improve the occlusion and facial aesthetics by maintaining good positioning of the condyle.

Endoscopically assisted intraoral modified Le Fort II type midfacial advancement using piezoelectric surgery and an intraoperative RED system.

PURPOSE: The Le Fort II midfacial advancement appears to be an effective surgical method for the treatment of severe midfacial-nose hypoplasia with a skeletal class III malocclusion, which is usually combined with syndromic midfacial anomalies. However, the conventional surgical method requires the coronal approach, including a coronal incision, together with other surgical approaches, such as an intraoral incision. Therefore, surgeons often hesitate to propose this type of osteotomy, even for patients who develop severe nonsyndromic midfacial-nose hypoplasia. This report presents a new surgical approach for performing a safe Le Fort II osteotomy for nasomaxillary, midfacial corrective advancement via a solely intraoral approach. MATERIALS AND METHODS: Surgery was performed with endoscopically assisted piezoelectric surgery. The osteotomized nasomaxillary Le Fort II segment was successfully protracted without aggressive down-fracture procedures with the sole intraoperative use of a rigid external distraction (RED) system, followed by internal rigid fixation, and the subsequent removal of the RED system. Seven patients (all patients were nonsyndromic, but 2 had cleft lip and palate, and an average age of 19.9 years) were included in this study. RESULTS: The degrees of midfacial advancement at the base of nasal bone (the top edge of the modified Le Fort II segment) that was osteotomized and at maxillary point A was 8.3 mm (range 5.8 mm to 10.5mm) and 8.5 mm (range 5.9 mm to 9.8 mm), respectively. CONCLUSION: This new method less invasively facilitates safe, secure, and ideal nasomaxillary midfacial protraction to yield a satisfactory resultant facial profile and favorable occlusion in patients with severe midfacial-nose hypoplasia and skeletal class III malocclusions.

Bone transport and bone graft using auto-tooth bone for alveolar cleft repair.

We herein report the application of a combination of maxillary bone transport and auto-tooth bone grafting for alveolar cleft repair using autogenous extracted teeth developed in Korea.A 9-year-old female patient suffering from unilateral cleft lip and palate was treated with this method. After sagittal interdental right-sided maxillary osteotomy was performed completely between #11 and #12 to the nasal floor, alveolar maxillary bone (#11, 21) was transported in the planned direction and the alveolar cleft was closed. At the end of the transporter activation period, soft tissue in the cleft was removed during so-called "docking surgery" using an electric knife for close bone contact at the docking site. We performed bone transporter removal and simultaneous auto-tooth bone grafting of the patient's supernumerary teeth to the docking site.Maxillary bone transport allowed for simultaneous correction of the nasal septal deviation, maxillary arch deformities, and malocclusion since the dental arch was expanded without donor sacrifice or soft tissue expansion. Auto-tooth bone grafting to the docking site allowed for repair of the bone defects of the nasal floor and alveolar cleft and resulted in a superior bone connection.A combination of maxillary bone transport and auto-tooth bone grafting to the docking site appears to be an effective approach for alveolar cleft repair.

Enhanced expression of Toll-like receptor 2 in lesional tissues and peripheral blood monocytes of patients with oral lichen planus.

Some members of the Toll-like receptor (TLR) family, which plays key roles in both innate and adaptive immune responses, are involved in the pathogenesis of autoimmune, chronic inflammatory and infectious diseases. However, the role of TLR in the pathogenesis of oral lichen planus (OLP) has not been investigated. The aim of this study was to understand the roles of TLR in OLP. The expression of TLR genes in OLP tissues was analyzed by cDNA microarray and reverse transcription polymerase chain reaction, and TLR protein expression in OLP tissues and peripheral blood monocytes was examined by immunohistochemical analysis and flow cytometry, respectively. Furthermore, TLR ligand-induced cytokine production from peripheral blood monocytes was measured by enzyme-linked immunosorbent assay. Among 10 TLR genes, the average expression ratio of the genes for TLR1, 2, 3, 5, 6 and 10 in OLP tissues compared to that in the normal buccal mucosae was more than 1.0. In contrast, the average ratio of the genes for TLR7, 8 and 9 was less than 1.0. TLR2 but not TLR4 was highly expressed in the cells of the spinous layer and infiltrating monocytes in OLP tissues, and the mean fluorescence intensity of TLR2 on peripheral blood monocytes was significantly higher in OLP patients than in healthy controls. Furthermore, the peripheral blood monocytes from OLP patients produced considerably higher amounts of interleukin (IL)-12 and lower amounts of IL-10 than those from healthy controls. In OLP, the T-helper cell (Th)1/Th2 balance appears to shift toward Th1 dominance, probably depending on the upregulation of TLR2 expression and these alterations in TLR2-mediated immunity may be involved in the pathogenesis and maintenance of OLP.

Combined evaluation of dihydropyrimidine dehydrogenase and thymidine phosphorylate mRNA levels in tumor predicts the histopathological effect of 5-fluorouracil-based chemoradiotherapy.

Recent clinical studies have indicated that intra-tumoral gene expression levels of 5-fluorouracil (5-FU) metabolism-related enzymes may predict the clinical response of several cancers to 5-FU-based chemotherapy. However, few studies examining oral squamous cell carcinomas (OSCCs) have been reported. In this study, we determined the expression levels of 5-FU metabolism-related enzymes like thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), thymidine phosphorylate (TP) and orotate phosphoribosyl transferase (OPRT) using reverse transcription-polymerase chain reaction (RT-PCR) combined with laser capture microdissection (LCM). We also evaluated the correlation between the mRNA expressions of these genes and clinico-pathological factors or the treatment effects of 5-FU-based chemotherapy combined with radiotherapy in 27 patients with OSCC. No significant correlation was observed between the mRNA expression levels of any of the examined genes and the T-stage, N-stage, differentiation grade or mode of tumor invasion. Although TS and OPRT mRNA were not correlated with the histopathological effects and the development of tumor recurrence, DPD and TP mRNA were significantly correlated with the histopathological effects and tumor recurrence. A significant positive correlation was also observed between the expression of TS and DPD mRNA, but no other correlations were observed among the other genes. Our results suggest that the combined evaluation of TP and DPD mRNA expression in tumor cells using LCM and RT-PCR may be a useful predictor of the efficacy of 5-FU-based chemotherapy combined with radiotherapy in patients with OSCC.

Thyroid carcinomas found incidentally in the cervical lymph nodes: do they arise from heterotopic thyroid tissues?

PURPOSE: Thyroid carcinomas have been found incidentally in the cervical lymph nodes during surgery for head and neck squamous cell carcinoma (SCC). Such carcinomas have been considered a metastatic focus for malignant transformation of heterotopic thyroid tissue. We report on cases of so-called occult thyroid carcinoma in the cervical lymph nodes, and review the relevant literature. PATIENTS AND METHODS: We encountered 3 cases of incidental papillary carcinoma in the cervical lymph nodes of patients with oral SCC, and consequently reviewed 75 previously reported cases. RESULTS: Among 148 patients with oral SCC who had undergone cervical lymph node dissection, 3 were diagnosed with occult thyroid carcinoma. Papillary carcinomas were found in 3, 10, and 3 lymph nodes in cases 1, 2, and 3, respectively. Computed tomography showed 2 tumor-like shadows and 1 calcified mass in the thyroid gland in cases 2 and 3, respectively. These shadows did not enlarge during the 3 to 5 years of observation, and all patients are alive, without any events related to the neck and thyroid gland. Among the reviewed cases, approximately two fifths were histopathologically or clinically free from thyroid carcinoma. Progressive thyroid carcinoma was not detected in any patient. CONCLUSIONS: We propose the possibility that thyroid carcinoma in the cervical lymph nodes is not necessarily metastatic, but may occasionally arise from heterotopic thyroid tissue.

Isolated metastasis from hepatocellular carcinoma to the mandibular condyle with no evidence of any other metastases: a case report.

Regional metastasis of hepatocellular carcinoma (HCC), the most common primary tumour of the liver to the mandible is rare. We present a case of a HCC metastasis to the mandibular condyle with no other extrahepatic metastases sites in a 59-year-old man. Incidental extrahepatic lesions in more uncommon sites should perhaps be investigated as potential areas for metastases, even if metastatic disease has not been found in the more common areas.

[Glandular odontogenic cyst: report of two cases with cytokeratin 18 expression].

OBJECTIVE: To report two cases of glandular odontogenic cyst and examine its cytokeratin 18,19 expression. METHODS: Two cases of glandular odontogenic cyst were reported and studied. The cytokeratin 18, 19 expression in these two cases were also investigated using immuno-histochemical staining as well as in the situ hybridization of the cyst epithelium. RESULTS: Histo-pathological examination revealed that ciliated columnar cells, squamous cells and low-columnar cells were found in the superficial layer of the lining epithelium. Several minor salivary glands, mainly composed of seromucous cells were observed near the satellite cyst. CK18 were expressed in all layers of the lining epithelium of varying intensity. CK18 was negative in lining epithelium of the daughter cyst, but CK19 was positive. CK18-mRNA was expressed in all the layers of the lining epithelium, the salivary glands and daughter cysts. CONCLUSIONS: Histological features and CK18 expression may be indicative of the possibility of salivary glandular and odontogenic differentiation.

Concomitant chemo-radio-immunotherapy has a lethal therapeutic effect on tongue carcinomas independent of the clinical stage and histological characteristics of the tumor.

We examined the effect of concomitant chemo-radio-immunotherapy on 80 patients with tongue carcinoma. Disappearance of the tumor without recurrence was observed in 21 patients (38.9%) in intravenous infusion chemotherapy group (A) and in 20 patients (76.9%) in intra-arterial infusion chemotherapy group (B) (P<0.005). A total of 41 patients (51.3%) were free from the tumor after the combined therapy. Along with the good therapeutic effect, oral function was preserved with minimal impairment of speech and mastication. Tumor stage, the mode of tumor cell invasion and tumor cell differentiation were not correlated with the therapeutic effect. In addition, the expression of p53, p21(Cip1/WAF1) and proliferating cell nuclear antigen did not differ between the patients with lethal and non-lethal effects. The 5-year-survival rate was 56.8% in Group A, 76.9% in Group B and 59.6% overall. Thus, combined chemo-radio-immunotherapy, especially intra-arterial infusion, may bring a universal therapeutic effect in tongue carcinoma regardless of the tumor stage and the expression of cell phase-regulating proteins.

Mechanism of HIF-1alpha-dependent suppression of hypoxia-induced apoptosis in squamous cell carcinoma cells.

The transcriptional factor hypoxia-inducible factor-1 (HIF-1) plays an important role in solid tumor cell growth and survival. Overexpression of HIF-1alpha has been demonstrated in many human tumors and predicts a poor response to chemoradiotherapy. We examined the HIF-1alpha-induced survival pathways in human oral squamous cell carcinoma cell (OSCC) lines. The results showed that forced expression of HIF-1alpha suppressed hypoxia-induced apoptosis of OSCC lines by inhibiting cytochrome c release from mitochondria. Overexpression of HIF-1alpha inhibited the generation of reactive oxygen species (ROS), elevation of intracellular Ca(2+) concentration, reduction of mitochondrial membrane potential, and cytosolic accumulation of cytochrome c, which resulted in the inactivation of caspase-9 and caspase-3. In addition, antiapoptotic Bcl-2 and Bcl-X(L) levels were increased and pro-apoptotic Bax and Bak levels were decreased in the HIF-1alpha-overexpressing OSCC line. Overexpression of HIF-1alpha also increased the levels of phosphorylation of Akt and extracellular signal-regulated kinases (ERK). These findings indicate that HIF-1alpha prevents apoptotic cell death through two mechanisms, including inhibition of cytochrome c release and activation of Akt and ERK.

Characteristic cytokine generation patterns in cancer cells and infiltrating lymphocytes in oral squamous cell carcinomas and the influence of chemoradiation combined with immunotherapy on these patterns.

OBJECTIVES: Cytokines produced by tumor cells and tumor-infiltrating lymphocytes (TIL) appear to regulate tumor cell growth and the cytotoxic activity of TIL. The objectives of the present study were to investigate cytokine generation patterns in tumor cells and TIL and to examine the influence of cancer therapy on this cytokine production and the cytotoxic activity of TIL. METHODS: We determined the levels of cytokines produced by tumor cells and TIL in vitro and measured the cytotoxic activity of TIL against Daudi cells in patients with oral squamous cell carcinoma (OSC) before and 1 week after the start of concomitant chemo-radio-immunotherapy. RESULTS: Before the therapy, OSC cells generated higher levels of granulocyte-macrophage colony-stimulating factor, tumor necrosis factor-alpha (TNF-alpha) and transforming growth factor-beta (TGF-beta) than did oral keratinocytes isolated from the noninflamed gingivae of healthy individuals, but both kinds of cells generated similar levels of interleukin (IL)-1beta and IL-6. Compared with peripheral blood mononuclear cells (PBMC) of the patients, TIL produced higher levels of IL-1beta, IL-6, IL-10, TNF-alpha and TGF-beta, whereas their production of IL-12 and interferon-gamma (IFN-gamma) was only slightly higher than that in PBMC. After 1 week of therapy, the cytokine production by OSC cells had largely decreased, while the production of TNF-alpha, IFN-gamma, TGF-beta and IL-12 by TIL had increased greatly, although other cytokine levels were almost constant during the investigations. The cytotoxic activity of TIL was higher than that of PBMC before the therapy, and this activity was strongly increased by 1 week of therapy. CONCLUSIONS: These results suggest that the cytokine productivities of TIL and tumor cells differ from those of PBMC and normal keratinocytes, respectively, and that chemo-radio-immunotherapy modulates in situ cytokine generation, which is advantageous for inhibition of tumor cell growth and activation of TIL.

Cytokeratin expression patterns in jaw cyst linings with metaplastic epithelium.

BACKGROUND: Cytokeratin (CK) expression patterns have been studied in numerous intact and diseased oral tissues. However, CK expression in metaplastic squamous cells has not been explored in depth and the origin of metaplastic epithelial linings of the jaw cysts has not been sufficiently investigated. METHODS: We examined CK expression in 46 postoperative maxillary cysts (POMCs) which were lined with pseudostratified columnar cells only, columnar and squamous cells, and squamous cells only, in 13, 30 and 3 cases, respectively. RESULTS: The expression of CK8, CK13 and CK18 were observed in 39, 9 and all 43 of the columnar epithelial linings, respectively. Metaplastic squamous epithelia expressed more CK13, and less CK18 and CK8. Of the 33 metaplastic linings, 24 expressed CK8, 23 CK13 and 26 linings expressed CK18. The patterns of expression of CK13 and CK18 observed were CK18(+)-CK13(-) in 10 metaplastic linings, CK18(+)-CK13(+) in 16, and CK18(-)-CK13(+) in 7. The expression of CK13- and CK18-mRNA was generally correlated with level of protein expressed. CK18-mRNA expression was observed by in situ hybridization, not only in the 26 metaplastic linings which were positive for CK18 protein, but also in five of the seven metaplastic linings which did not express CK18 protein. In addition, RT-PCR revealed an expression of CK18-mRNA in all metaplastic squamous linings, although the expression level was weaker than that in the columnar epithelial linings. The CK13-mRNA was expressed inversely to the CK18-mRNA. CONCLUSIONS: These results indicate that CK18-mRNA is preserved through metaplasia, although the protein expression decreased. Metaplastic squamous cells differentiate with a decrease of CK18 and an increase of CK13 expression.