Need for symptomatic management in advanced multiple sclerosis.

OBJECTIVE: A majority of patients with advanced multiple sclerosis (MS) need symptomatic treatment. Many MS-related symptoms may not be recognized and thus are not treated. We conducted a study to estimate the prevalence of inadequate symptomatic treatment of patients with advanced MS. METHODS: Patients with advanced MS admitted to a specialist MS rehabilitation clinic were included in this study. Severity was assessed using the Expanded Disability Status Scale (EDSS). The information we collected included age of onset, initial course, time to sustained disability, pharmacological treatment, degree of spasticity, pain and bladder dysfunction, and unmet needs of symptomatic treatment. RESULTS: In total, we assessed demographic and clinical characteristics in 129 patients with a mean age of 56 years and a median EDSS of 7.5. The proportion with inadequate symptom treatment was regarding spasticity 46%, pain 28%, and bladder dysfunction 23%. DISCUSSION: This study showed that a large proportion of patients with advanced MS had lack of symptomatic treatment. These patients probably underuse neurological specialist services. Better symptomatic treatment could contribute to improving quality of life of people with MS.

Head and neck reconstruction using microsurgery: a 9-year retrospective study.

A total of 137 patients diagnosed with head and neck cancer underwent ablative surgery and primary free flap reconstruction during a period of 9 years, 2001-2009 (men 73.7 %, women 26.3 %). Surgery included a multidisciplinary approach involving plastic, head and neck, and maxillofacial surgeons. Squamous cell carcinoma (SCC) represented the vast majority of the diagnosed tumors (91.2 %); other tumors represented in the study were malignant melanoma, sarcoma, adenocarcinoma and blastoma. The free flaps (n = 143) used for reconstructive surgery included radial forearm flap (n = 128), fibular flap (n = 13) and rectus abdominis muscular flap (n = 2). Twenty patients (15 %) needed reoperation within 48 h due to clinical signs of hematoma (n = 8) and free flap ischemia (n = 12). Furthermore, we report a total of 12 free flap failures, giving an overall free flap success rate of 92 %. Five patients were treated due to infections at donor site (4 %). The overall survival rate (OS) in male patients diagnosed with oral SCC stage II-IV after 2 and 5 years was 82 and 78 %, respectively. Female patients in the same group displayed a 2- and 5-year OS of 78 and 67 %, respectively. Furthermore, analysis of patients treated for recurrence of primary SCC displayed a 2- and 5-year OS of 70 and 55 %, respectively. We conclude that our multidisciplinary approach and treatment algorithm for head and neck cancer including primary free flap reconstruction reconstitutes a safe and reliable tool.

Metal fragment in the temporomandibular joint: a case report.

A 56-year-old woman was referred for severe pain and restricted jaw movements with a duration of more than 10 years. In the early 1990s a discectomy on the left side had been performed where the disc was extirpated and replaced with a polymeric implant. Due to infection and pain the implant was removed about 2 months later. In the 10-year period thereafter she suffered pain from the joint, pain from the left ear, tinnitus and restricted mouth opening.A computer tomography scan revealed a foreign body, approximately 4mm in size, situated in the medial part of the glenoid fossa. The metallic foreign body was surgically removed. The pain from her left temporomandibular joint decreased and the mouth opening capacity increased. Patch-testing showed that the patient had a potential for contact allergy to nickel, chromium and cobalt. The foreign body was most probably a fractured tip of a surgical awl. Energy dispersive X-ray analysis revealed that the fragment consisted of iron and chromium. The instrument fragment could have caused the symptoms either by an allergic reaction or a direct mechanical effect.

Clinical behaviour of glass ionomer restorations in primary teeth.

OBJECTIVE: To compare a silver-reinforced glass ionomer material (cermet) with a resin-modified glass ionomer in minimal Class II preparations in primary teeth. METHODS: Matched pairs of primary molars with approximal caries that required operative treatment were used. Each cavity was filled with either Vitremer or Ketac-Silver. The restorations were followed for at least 36 months and examined annually using bitewing radiographs and clinical inspections. Impressions were taken at each recall and models were examined microscopically. RESULTS: After 36 months, one of the resin-modified glass ionomer (RMGI) restorations and 13 (26.5%) of the silver cermet restorations had failed. The RMGI failed because of secondary caries, while most of the failures of the silver cermet fillings were marginal defects alone or in combination with secondary caries. The median survival time (MST) for the silver cermet restorations was 37 months. The RMGI restorations had a MST exceeding 42 months, but MST could not be calculated exactly because of the low failure rate during the study period. CONCLUSIONS: The resin-modified glass ionomer had the overall best performance of the two materials under comparison. The silver cermet material cannot be recommended for Class II restorations in primary teeth.

Stability after Le Fort I osteotomy in cleft lip and palate patients.

Le Fort I osteotomies were performed in 20 patients with cleft lip and palate as a one-segment movement, and the fragments were fixed with miniplates without bone grafting. Tracings of preoperative and serial postoperative lateral cephalograms were used to determine changes in maxillary position. The posterior nasal spine, not subjected to extensive changes during surgical procedures and remodeling, was found to be the most reliable landmark for measuring maxillary advancement and stability. The mean maxillary advancement was 5.96 mm. Analysis did not reveal significant changes in linear and angular measurements from immediately postoperative to 6 months postoperative. A modest maxillary advancement by Le Fort I osteotomy, along with alleviation of palatal scar tissue tension and miniplate fixation, is a stable surgical method in patients with cleft lip and palate.

Guided tissue regeneration and local delivery of insulinlike growth factor I by bioerodible polyorthoester membranes in rat calvarial defects.

Thirty 8-week-old male Wistar rats were randomly allocated into three groups of 10 rats each. A 5-mm defect in the left parietal bone was made in each rat. In the defects of the first group of rats, no implant was used (control group). In the second group, polyorthoester membranes were placed in the defects without active substance. In the third group, polyorthoester membranes were placed with insulinlike growth factor I. The rats were sacrificed 6 weeks postoperatively. Bone formation in the defects was quantified by computer-assisted measurements of the area of the residual defect on radiographs. Host-tissue response was evaluated by light microscopy. The area of residual bone defect was greatest in the control group, less for the defects with polyorthoester membrane without active substance, and least for the defects with polyorthoester membranes with the growth factor. During histologic evaluation, no inflammation was seen, and only traces of the polyorthoester were detected in the defects with polyorthoester membrane with or without the growth factor.

Cranial dislocation of the mandibular condyle. A case report with an unusual hearing loss.

The case of a 37-year-old woman who suffered a condylar dislocation into the middle cranial fossa is reported. The mechanisms of injury, the problems of clinical diagnosis and the management are discussed.

Skeletofacial changes by mandibular advancement using sagittal split osteotomies.

Forty-five patients with mandibular retrognathism treated by surgical mandibular advancement by sagittal split osteotomies were evaluated cephalometrically before treatment at the intermaxillary fixation release, and 6 months postoperatively. The treatment resulted in appreciable improvement of the mandibular retrognathism, and the facial morphology was changed positively toward normal values. The mandibular prognathism was accomplished by an anterior displacement of the mandibular corpus and by a slight increase of the mandibular corpus length. The anterior facial height and the mandibular plane angle were increased by a clockwise rotation of the anterior segment and a counterclockwise rotation of the posterior segment, which consequently increased the gonial angle. These changes partly reversed during the postfixation period. Dentoalveolar changes were found in the position of the maxillary and mandibular incisors; both were uprighted, the mandibular incisors more than the maxillary incisors. In general, the long-term positive effects of the surgical mandibular advancement revealed great stability.

Maxillofacial fractures in a Norwegian district.

Records of 169 patients referred to Haukeland Hospital, Bergen, Norway, for treatment of maxillofacial fractures during the period 1989-91 were studied with respect to socio-etiologic aspects, frequency and localization of jaw fractures, treatment, and complications. The number of maxillofacial fractures found in the present study was about twice as many as found in a study from the same area during the period 1974-9. Recent trends in the etiology of maxillofacial traumas were confirmed, such as increased number of fractures caused by interpersonal violence, and a reduction of cases related to traffic accidents. Alcohol abuse was a contributing factor in 28% of the patients. Mandibular fractures were 4.8 times more frequent than maxillary fractures. Reduction and fixation with miniplate osteosynthesis was the preferred treatment in most patients.

[Hemifacial microsomia: development, diagnosis and surgical correction]. / Hemifacial mikrosomi--utvikling, klinikk og kirurgisk behandling.

Hemifacial microsomia is the second most common congenital facial anomaly. It occurs as a spontaneous event during embryogenesis and involves structures derived from the first and second branchial arch. In the past treatment of the skeletal defect was delayed until the child ceased growing and end-stage of the deformity was reached. More recent approach to analysis and treatment of this anomaly, emphasizing early treatment, to give the patient the maximum benefit of a combined surgical and orthodontic therapy, is described.

Positioning and mobility of the mandibular condyle after surgical correction of the asymmetric, prognathic mandible.

Following the extraoral vertical subcondylar osteotomy in the correction of the highly asymmetric and prognathic mandible, only insignificant radiographic changes were observed in the temporomandibular joint 12 months postoperatively. Slight morphologic alterations of the condylar seating were demonstrated at occlusion, but there was no significant difference in condylar position between the two sides of the surgically corrected asymmetric mandible. The condylar axis did not deviate from the preoperative situation, and condylar axis did not deviate from the preoperative situation, and condylar mobility was fully resumed 12 months postoperatively. The extraoral vertical subcondylar osteotomy procedure is applicable in the treatment of combined mandibular asymmetry and prognathism and does not create morphologic changes that differ in the two temporomandibular joints.

Osteotomy length and postoperative stability in vertical subcondylar ramus osteotomy.

The osteotomy sites in 80 patients treated for mandibular prognathism by intraoral (IVSO) or extraoral (EVSO) vertical subcondylar ramus osteotomy and their relationships to post-operative mandibular stability were studied. A model study demonstrated that metric orthopantomographic measurements of the ramus showed insignificant variability of magnification and distortion. The relative osteotomy length and the bony overlapping area of the osteotomized fragments were evaluated on 6-week postoperative orthopantomograms. High correlation was found between the clinical estimate of osteotomy length and metric registrations. Bony overlapping area of the IVSO and the EVSO group did not reveal differences. The mandibular positional changes during the fixation/postfixation periods were analyzed on 6-week and 6-month postoperative lateral cephalograms. Significant correlations could not be demonstrated between postoperative stability and osteotomy length or overlapping bony area. Thus the osteotomy length appears to be factor of minor importance for postoperative stability.

Stability after vertical subcondylar ramus osteotomy for correction of mandibular prognathism.

A cephalometric analysis of the positional changes of the mandible and the upper and lower incisors following vertical subcondylar ramus osteotomy was performed on 80 patients. The patients were prognathic without laterognathism or open bite and all the patients had preoperative orthodontic treatment. 40 patients were operated with an intraoral (IVSO) and 40 with an extraoral approach (EVSO). Both groups showed postoperatively posterior rotation of the mandible, shortening of the posterior facial height, increase in anterior facial height and extrusion of the incisors in both jaws. A significantly greater reduction of posterior facial height was observed in the EVSO-group, but otherwise the 2 groups did not reveal any statistically significant positional differences. The material was sub-divided into 2 groups 1 with (n = 32) and one group without (n = 48) extra skeletal (nasomandibular) fixation in addition to the intermaxillary fixation. Significantly less positional changes of the incisors and less increase of anterior facial height was found in the group with skeletal fixation, but the influence on other skeletal alterations was limited. After release of the intermaxillary fixation, the only difference between the groups was intrusion of the earlier extruded incisors, most pronounced in the group without skeletal fixation.

Extraoral and intraoral vertical subcondylar ramusosteotomy for correction of mandibular prognathism.

Vertical subcondylar ramusosteotomy for correction of mandibular prognathism was performed in 203 cases with an extraoral (EVSO) and in 55 cases with an intraoral (IVSO) approach. Clinical and surgical observations were analyzed and the 2 techniques compared with regard to operation time, per- and postoperative complications, postoperative morbidity of the patients and the duration of hospital stay. The extraoral approach demonstrated significantly shorter operation time, less blood loss and shorter hospital stay. The extent of postoperative swelling, nausea and vomiting was also in favour of the EVSO. Serious complications were few, and both techniques were considered as satisfactory and safe.

The surgical technique of vertical subcondylar osteotomy for correction of mandibular prognathism. A 10-year survey.

In the period 1975-1985 extraoral vertical, subcondylar osteotomies of the mandibular ramus (EVSO) were performed in 203 patients with mandibular prognathism at Haukeland University Hospital, Bergen. Refinements of this surgical technique are described. Clinical and surgical observations were analyzed as to preoperative orthodontic treatment, operation time, pre-/post-operative complications, and hospital stay. The findings confirm that the EVSO procedure is a safe technique, with minimal discomfort and morbidity for the patients. Even though intraoral procedures are the trend for surgical correction of mandibular prognathism at present, there are substantial indications for the use of EVSO.

Surgical correction of mandibular prognathism in Norway, 1975-1984. A national survey.

The estimated need for surgical correction of mandibular prognathism in Norway is 500 patients each year. A questionnaire sent to the maxillofacial surgical units performing orthognathic surgery in Norway showed that in the decade from 1975 to 1985 altogether 1169 patients underwent surgical correction of mandibular prognathism; that is, only 117 patients were treated yearly [corrected]. Extraoral vertical subcondylar osteotomy of the mandibular ramus was the preferred surgical technique, performed on 57% of the patients. Intraoral vertical subcondylar osteotomy of the ramus increased in use and thus seems to be taking over for the extraoral technique. Sagittal split osteotomy was used on 25% of the patients. The different units showed great variation in their preference for the different surgical techniques. Preoperative orthodontics was widely used, on a mean of 77% of the patients. The average hospital stay was 8.5 days, somewhat longer than reported from other countries; however, geographical conditions should be taken into consideration.

Geographical distribution, preoperative orthodontics, and morbidity of Norwegian patients surgically treated for mandibular prognathism.

The geographical distribution of 1169 Norwegian patients operated on for mandibular prognathism during the years 1975-1984 showed an accumulation of cases in the western and northern parts of the country. This skew distribution was probably due to genetic factors. No association was found between the number of operated patients and the number of orthodontists or oral and maxillofacial surgeons in the different counties. Most of the patients (69%) had less than 2 years and 10% had more than 4 years of preoperative orthodontic treatment. The use of presurgical orthodontics seemed to increase during the observation period, and the mean treatment time was shorter in the last half of the decade. The morbidity, defined as the duration of the hospital stay and the intermaxillary fixation period, was on an average 56 days, mostly dependent on the surgical unit.

Central mucoepidermoid tumour of the mandible. Report of 2 cases.

Central mucoepidermoid tumour is an uncommon tumour within the jawbones. The onset is insidious and the first symptom is usually swelling. The radiographic appearance resembles a multiocular cyst or ameloblastoma. Two new cases are presented, and their diagnosis, histopathology and treatment are discussed. The prognosis is fairly good after adequate surgical treatment.