Oral and Maxillofacial Surgery

Abstract Purpose The aim of this study was to evaluate the long-term health-related quality of life (HRQoL) of head and neck cancer patients with microvascular surgery. Surgical treatment causes great changes in patient HRQoL. Studies focusing on long-term HRQoL after microvascular reconstruction for head and neck cancer patients are scarce. Methods We conducted a prospective study of 93 patients with head and neck cancer and microvascular reconstruction in Helsinki University Hospital Finland. HRQoL was measured using the 15D instrument at baseline and after a mean 4.9-years follow up. Results were compared with those of an age-standardized general population. Results Of the 93 patients, 61 (66%) were alive after follow-up; of these, 42 (69%) answered the follow-up questionnaire. The median time between surgery and HRQoL assessment was 4.9 years (range 3.7–7.8 years). The mean 15D score of all patients (n = 42) at the 4.9-years follow up was statistically significantly (p = 0.010) and clinically importantly lower than at baseline. The dimensions of “speech” and “usual activities” were significantly impaired at the end of follow up. There was a significant difference at the 4.9-years follow-up in the mean 15D score between patients and the general population (p = 0.014). After follow up, patients were significantly (p < 0.05) worse off on the dimensions of “speech,” “eating,” and “usual activities.” Conclusions Long-term HRQoL was significantly reduced in the whole patient cohort. Speech and usual activities were the most affected dimensions in head and neck cancer patients with microvascular reconstruction at the end of the 4.9-years follow up.

Abstract Purpose The aim of the present experiment was to compare the data on new bone formation measured histologically and microtomographically in maxillary sinuses augmented with a xenograft with higher density and higher mineral content compared with the natural bone. The hypothesis was that histomorphometric and micro-computed tomography (microCT) analyses do not yield similar outcomes when a xenograft with higher density and mineral content compared with the natural bone is used. Methods In 18 rabbits, the maxillary sinus was augmented bilaterally using deproteinized bovine bone mineral (DBBM) xenograft granules of either 0.125–1 mm or 1–2 mm of dimensions. The rabbits were euthanized after 2, 4, and 8 weeks of healing. Comparisons were performed between microCT and histological analyses. Results After 2 weeks of healing, higher contents of bone were found at the histological compared with the microCT analyses in both sinuses, especially in the middle regions of the grafted sinus. Between 2 and 8 weeks of healing, new bone increased of about 21% at the histological analyses while, at the microCT, increased only about 4%. In the same period, the xenograft proportion decreased from 51.6 ± 4.9 to 45.3 ± 3.3% at the histological analyses while, at the microCT, the xenograft appeared to increase in percentages. Conclusion Histological and microCT analyses yielded different outcomes when a xenograft with higher density and higher mineral content compared with the natural bone was used.

Abstract Purpose This study aims to investigate rehabilitation strategies to reduce trismus, pain, and edema in patients with maxillofacial trauma. Methods An electronic search in main databases was performed, including studies published until November 2017. Clinical trials aiming to investigate therapeutic techniques to improve mandibular range of motion and to reduce pain and edema compared to other treatments were included. Results Nine studies were included in the review with different therapy modalities: photobiomodulation, kinesiologic tape, hilotherapy, jaw exercises, and TENS. Only five studies had available data to be included in a meta-analysis. There were no differences between any of the proposed strategies and its controls to prevent trismus. Individuals treated with hilotherapy presented less pain compared to controls. Kinesiologic tape or hilotherapy reduced edema when compared to controls daily until postoperative day 3. Conclusions There is diversity among the proposed rehabilitation techniques, and types of fractures and there are few numbers of included participants in each study. The results obtained in this review do not promote evidence to guide the use of non-drug rehabilitation techniques in patients with maxillofacial trauma after surgical intervention.

Abstract Purpose The aim of the current study was the retrospective analysis of the outcomes of teeth treated with apical surgery after a 1-year follow-up period. Furthermore, potential factors associated with the success rate were investigated. Methods All patients were treated at the Clinic of Cranio-Maxillofacial and Oral Surgery at the University of Zurich between 2010 and 2017. To be eligible for inclusion, all patients were required to have undergone apical surgery with a retrograde root-end filling, and a 1-year follow-up examination at the University of Zurich. Treatment success at the 1-year follow-up time-point was defined as an absence of clinical complaints and radiographically determined healing. Parameters that were analysed included tooth localisation, periapical index of the preoperative lesion, administration of antibiotics, smoker status, histopathology of the apical lesion, radiographically determined sufficiency of root canal treatment pain and clinical signs of inflammation at the initial examination. Results A total of 81 teeth fulfilled all the inclusion criteria. At the 1-year follow-up, 91.4% of the teeth exhibited successful clinical and radiographic healing. The type of tooth was significantly associated with the success of the surgery (p = 0.006), but radiological severity of periapical inflammation, lesion histopathology, administration of antibiotics, smoker status, the quality of the root canal treatment, and preoperative pain and clinical signs of inflammation were not. Conclusion The results of the present study suggest that apical surgery with retrograde root-end filling is a reliable therapy for the preservation of teeth. Furthermore, there are limited factors that affect the treatment outcome.

Abstract Purpose This study was to assess the efficiency of using a combination of one microplate and one miniplate for management of patients with parasymphyseal mandibular fractures versus two miniplates through measurement of the biting force. Patients and methods The study sample consisted of sixteen patients with an isolated mandibular fracture and randomly divided into two groups; group I was managed using two miniplates, while group II was managed using a combination of one microplate at subapical region and one miniplate at the inferior border of the mandible. The biting force was measured at 1 week, 1 month, and 3 months follow-up visits. A control group consisted of 40 healthy adult volunteers was selected to measure the normal biting force. Results The mean of the normal biting force of the control group was 435 N ± 219, 103.2 N ± 4.8, and 390.6 N ± 195.4 at right molar, incisor, and left molar regions respectively. There was a statistically non-significant difference regarding the bite force of both study groups, with a progressive increase through the different follow-up visits and a period of 3 months is sufficient for recovery of patients to regain their normal biting force. Conclusion Consequently a combination of one microplate and one miniplate is efficient for the management of isolated parasymphyseal mandibular fracture in the same way as two miniplates.

Abstract Purpose Mandibular third molar extractions are common treatment in oral maxillofacial surgery, but risk disturbance of the lingual nerves causing anesthesia, eating difficulty and allodynia, which can seriously reduce patient quality of life. This study investigates the change in allodynia before and after repair in patients with lingual nerve disorder. Subjects and methods This retrospective cohort study comprises the 52 patients with affected lingual nerve after third molar extraction at our hospital over a 7-year period. Pre- and postoperative (6 months and 12 months) neurosensory records were analyzed. Results Fifty-two patients underwent lingual nerve repair and returned for at least 1 year of follow-up. Mean age was 36.8 ± 11.9. Median interval between injury and surgery was 5 (4, 8) months. In 92.9% of those with pain before surgery, allodynia disappeared postoperatively. Conclusions This study shows that microsurgical lingual reconstructions are effective in patients with preoperative allodynia, but a small number of patients may have remaining allodynia after surgery. Large-scale, more detailed analysis of such cases is required.

Abstract Purpose Orbital decompression is an established surgical treatment option for a range of orbital conditions. We report the outcomes of endonasal decompression to recess the globe for conditions and pathologies other than thyroid eye disease. Methods This was a retrospective case series of patients who underwent endoscopic orbital decompression for proptosis secondary to non-thyroid eye disease orbital pathologies. The procedures were carried out by oculoplastic surgeons across two hospital sites between January 2011 and July 2018. Information collected includes patient demographics, diagnosis, surgical details, pre- and postoperative clinical findings (including visual acuity, exophthalmometry readings, intraocular pressure, ocular motility and diplopia), complications and further treatment. Results There were seven cases of endoscopic decompression, each due to a different pathology. The reasons for decompression were proptosis secondary to optic nerve sheath meningioma (1); sphenoid wing meningioma (1); idiopathic myositis (1); axial myopia (1); chronic third nerve palsy (1); to protuberant keratoprosthesis (1); and Crouzon syndrome with corneal exposure (1). Visual acuity remained stable or improved in all patients postoperatively. There was an average reduction in proptosis of 3.5 ± 1.4 mm (standard deviation - SD). Ocular motility remained stable in 100% (7/7). There were no intraoperative or postoperative complications, including no new cases of postoperative diplopia. Conclusions Endoscopic orbital decompression can be performed for patients with proptosis associated with a large globe, facial dysplasia or medial and infero-medial orbital lesions.

Abstract Purpose To assess epidemiological, clinical, and radiographic characteristics of odontogenic cysts (OCs) in a South Brazilian sample and to compare the results with international literature. Methods For the main study purposes, biopsy and histopathological records were retrospectively analyzed from December 2006 to December 2018, OC cases were selected, and data about clinical characteristics were evaluated. Further, a literature review was performed for similar studies. Results In the main study, the prevalence of OCs was 11.26% (n = 406), the majority of patients was male (56.73%), and the mean age was 39 ± 17.33 years. Radicular cyst was the most common OC (46.06%), followed by the odontogenic keratocyst (15.02%), dentigerous cyst (14.04%), and paradental cyst (13.55%). Inflammatory OCs were more prevalent in the maxilla (54.84%) and developmental cysts in the mandible (69.92%) (p < 0.05). Individuals with inflammatory OCs were usually older (41.0 ± 15.34 years) than the ones with developmental OC (28.0 ± 19.68 years) (p < 0.05). Regarding the literature review, 22 articles were included. Analysis of pooled data showed that global prevalence of OCs was 11.62% (95%CI = 9.97–13.37), from which radicular cyst was the most common (54.26%; 95%CI = 49.30–59.18), followed by dentigerous cyst (22.94%; 95%CI = 19.22–26.89) and odontogenic keratocyst (11.99%; 95%CI = 8.88–15.49). Furthermore, studies from Asia (72.40%; 95%CI = 70.30–74.40) and South America (68.48%; 95%CI = 64.07–72.72) presented the highest frequencies of inflammatory OCs. Conclusion The main study showed that the prevalence of OCs was 11.26%, which corroborates with international literature. Considering geographic variability of OC distribution, public health authorities and researchers could use these data for the development of focused prevention interventions, especially with regard to inflammatory OCs.

Abstract Aim and objective A prospective study done to evaluate the efficacy of tongue flaps in secondary palatal defects, in terms of functionality, esthetics, and donor site morbidity, and to clarify the technique of elevating and insetting of tongue flap. Materials and method Twenty patients having recurrent secondary palatal fistula, post cleft treatment were treated with anteriorly and posteriorly based dorsal tongue flaps. Patients were evaluated for outcome in terms of flap uptake and effectiveness, correction of oronasal regurgitation, speech and articulation, donor site morbidity, and esthetics. Results Twenty patients in age range of 11–24 years, with secondary palatal fistulae, were treated with anteriorly/posteriorly based tongue flap. There were two recurrences as the flap got detached in one patient and necrosis of flap in another. In other patients, healing was uneventful. The flap showed good success rate in terms of uptake and correction of oronasal regurgitation, with imperceptible donor site morbidity. With speech therapy assistance and periodic evaluation by a therapist, significant improvement in speech and articulation was noted over time in all successfully healed patients. Conclusion Use of tongue flap for repair of palatal fistulae is a successful technique as it provides appreciable quality and quantity of well-vascularized tissue for fistula closure with negligible functional and esthetic morbidity associated with donor site. As per our study, it is a reliable technique for palatal fistula closure. It even provides good speech improvement over time.

Abstract Purpose The purpose of this study was to compare primary and secondary wound closure with a buccal mucosal-advancement flap technique on the postoperative course after mandibular impacted third molar surgery. Methods The study was conducted on 150 patients who required surgical removal of impacted mandibular third molars under local anesthesia. The study subjects were divided into three groups of 50 patients each, based on the type of closure over the third molar socket. Patients in group I underwent primary closure of the socket with hermetic suturing of the flap, including the vertical release. In group II, a secondary closure was performed, leaving the socket communicating with the oral cavity. In group III, a buccal mucosal-advancement flap technique was employed to achieve primary closure of the flap over the socket while leaving the anterior vertical release, generously patent. All the patients were assessed for pain using the visual analogue scale (VAS), swelling, and mouth opening at postoperative intervals of 2, 4, and 7 days. The wound healing was assessed on day 7. Results Patients in the buccal mucosal-advancement flap group had significantly less pain and swelling and increased mouth opening compared with primary and secondary closure. Wound dehiscence was seen in 18 patients and alveolar osteitis in 4 patients in primary closure. Delayed wound healing with food accumulation was seen in 6 patients in secondary closure. No complications of flap dehiscence or breakdown were observed in the buccal mucosal-advancement flap group. Conclusion This study concludes that the buccal mucosal-advancement flap technique was a superior closure technique with less pain, swelling, trismus, and satisfactory wound healing compared with both primary and secondary closure after mandibular third molar surgery.

Abstract Purpose Sublingual hematoma is a rare complication seen in bleeding disorders, trauma, dental procedures, and the use of anticoagulants. Only a few publications have described idiopathic spontaneous sublingual hematoma, and all of them suspected severe hypertension as etiology. Our objective is to present a case of idiopathic spontaneous sublingual hematoma in a 48-year-old patient without any medical history of hypertension and to perform a literature review on this subject. Methods Case report presentation based on information extracted from the electronic patient database of Ghent University Hospital including a literature review of sublingual hematoma. Results This case report describes a 48-year-old male patient presenting with a spontaneous sublingual hematoma, which needed to be treated with an urgent tracheotomy. Drainage of the old hematoma followed 11 days later. He was not known with hypertension or any bleeding disorder. Clinical examination using fiberoptic nasolaryngoscopy, a CT scan, MRI scan, and biopsy of the sublingual salivary gland showed no focus for etiology. Conclusions Clinical work-up is necessary to look for a cause of a spontaneous sublingual hematoma. Idiopathic spontaneous hematoma is only a rare entity. Aggressive airway management should be the first step in treatment. To date, there is no consensus about the management regarding the hematoma itself. Mostly, clinicians start with observation for spontaneous resolution of the hematoma and when possible to treat causative factors. Surgical drainage is performed when conservative treatment is not sufficient.

Abstract Introduction Lymphangiomas are relatively uncommon head and neck region lymphatic malformations. Although surgery can be still considered the mainstay of treatment, sclerotherapy by OK-432 is becoming a widespread treatment option. The aim of this article is to present and discuss the management and outcomes of a series of cases of lymphangiomas. Methods All patients with lymphangiomas who were treated from 2010 to 2018 were reviewed. The following data were recorded: age, gender, subtype, staging, type of treatment, outcome, and recurrence. Results Fifteen patients (9 females, 6 males) were included with 2 microcystic and 13 macrocystic lymphangiomas. Six patients underwent surgery with excision (5 with a complete success, one with a fair success), whereas the remaining 9 subjects underwent sclerotherapy by OK-432 (6 with a complete success, 3 with a fair success). No postoperative complications were observed. Conclusions All modes of treatment are important in properly selected patients affected by lymphangiomas. OK-432 therapy is a safe and effective option in the treatment of head and neck lymphangiomas.

Abstract Background Mucinous adenocarcinoma (MAC) rarely occurs in the salivary glands, especially in the labial gland. MACs arising from the salivary glands are characterized by an aggressive behavior due to high invasiveness and a high rate of regional lymph node metastasis. Case presentation Here, we report a case of MAC arising from the lower lip, shown to have elevated serum carcinoembryonic antigen (CEA) levels by the medical checkup. The tumor showed aggressive behavior and serum CEA levels increased with repeated recurrence. CEA has been shown to have surprisingly diverse functions in cell adhesion, intracellular and intercellular signaling, and complex biological processes such as cancer progression, inflammation, angiogenesis, and metastasis. A MAC arising from the salivary glands may have a poor prognosis because CEA is highly expressed. Conclusions Generally, serum CEA levels have not been used as tumor markers for salivary gland malignancies; however, it may be useful for MAC arising from salivary glands. We recommend prospective research to determine whether serum CEA estimation is useful as a component of routine pre-treatment workup for MACs arising from the salivary glands.

Abstract Introduction The aim of this study was to assess the relationship between the status and position of third molars, and the presence of mandibular angle and/or condylar fractures, in a group of patients treated for mandibular fractures, thus hoping to contribute to the knowledge of potential predictors of these fractures. Methods A retrospective study was designated to include all the patients who were diagnosed and treated with open reduction and internal fixation for isolated mandibular angle fractures or isolated mandibular condylar fractures between 1st of January 2012 and 31st of December 2018. The following data were collected for each included patient: gender, age, etiology, site and side of the fracture, and presence and eruption state of third molars in the fracture side. Results Seventy patients were diagnosed with a condylar fracture, 48 with an angle fracture. No statistically significant difference was observed as for etiology and gender distribution between angle fracture and condyle fracture patients (p > 0.05). Angle fractures were statistically associated with the presence of third molars, whereas condylar fractures with the absence of third molars (p < 0.000005). The presence of completely erupted 3Ms was associated with condylar fractures (p < 0.05), and partially impacted 3Ms were associated with angle fractures (p < 0.0005). Conclusions Mandibular angle fractures and third molar presence are associated in patients who present with mandibular fractures, especially if the third molar is incompletely erupted. This information should be kept in consideration as for the diagnosis and management of patients with mandibular fractures.

Abstract Purpose Myeloid sarcoma (MS) is defined as a tumorous mass of myeloblasts or immature myeloid cells involving an extramedullary anatomic site. MS occurs in 3 to 8% of patients with acute myeloid leukemia. The overwhelming majority of MS occurs in the skin, bones, and gastrointestinal tract; intraoral MS (IMS) is extremely rare. Methods We describe a case of MS of the mandibular gingiva in a patient with acute myeloid leukemia that was in remission. We also present a review of the English and Japanese literature with a special focus on the management and prognosis of intraoral MS. Results The patient was discharged while in remission 8 months after the initial examination. Conclusion The prognosis of IMS is extremely poor in general, and a diagnostic delay can prevent adequate therapy by hematologists and oncologists. All dental clinicians must keep the possibility of IMS in mind and carefully examine all patients with AML.

Abstract Purpose The aim of this study was to analyze the clinical features of BSCC in the oral cavity, diagnosed over 31 years of service in oral pathology, and make comparisons with the data reported in the literature. Methods Data regarding gender, age, clinical presentation, anatomical location, symptoms, evolution time, size of lesion, and use of alcohol and tobacco from cases of BSCC were collected. Additionally, we conducted a review of BSCC studies from searches in three electronic databases. Results Among 24,570 oral biopsies, 7 (0.03%) were BSCC and represented 0.8% of oral squamous cell carcinoma (n = 875). All cases occurred in males, and the prevalent affected age was the sixth decade (60%). Ulcers occurred in all cases, with the majority showing no symptoms (71.4%). The tongue (30.8%), alveolar ridge/gingiva (30.8%), and floor of the mouth (23.1%) were the anatomical locations affected. The literature review indicated a total of fifteen publications, reporting 214 cases of BSCC. Males (76.7%) in the seventh (53.3%) decade of life were most affected. According to the cases with adequate information, symptomatic (90.0%) ulcers (80.0%) in the floor of the mouth (42.1%), with a mean size of 2 cm and the mean evolution time of 1.5 to 18 months were the most seen. Association with tobacco and alcohol use, when noted, was 50.0%. Conclusion The features presented in this study are more similar than different when compared with the literature data.

Abstract Introduction Management of body fractures in patients with edentulous atrophic mandibles represents a challenging task due to patient’s age, medical comorbidities, poor bone quality, and vascularity, as well as reduced contact area between the fracture ends. The aim of the study was to assess the demographic and clinical variables, the surgical technique, and outcomes of unilateral body fractures of the edentulous atrophic mandible managed at several European departments of oral and maxillofacial surgery. Methods This study is based on a systematic computer-assisted database that allowed the recording of data of all patients with fractures of the atrophic edentulous mandible from the involved maxillofacial surgical units across Europe between 2008 and 2017. The following data were recorded for each patient: gender, age, comorbidities, etiology, synchronous body injuries, degree of atrophy of the mandible according to Luhr classification, type of surgical approach and fixation, length of hospitalization, and presence and type of complications. Results A total of 43 patients were included in the study: 17 patients’ mandibles were classified as class I according to Luhr, 15 as class II, and 11 as class III. All patients underwent open reduction and internal fixation by extraoral approach in 25 patients, intraoral in 15 patients, and mixed in 3 patients. A single 2.0 miniplate was used in 16 patients, followed by a single 2.4 reconstruction plate in 13 patients, by two 2.0 miniplates, and three 2.0 miniplates. Outcome was considered to be satisfying in 30 patients, with no complications. Complications were observed in 13 cases. Conclusions Treatment of unilateral body fractures of the edentulous mandible must still be based on the type of fracture, degree of atrophy, experience of the surgeon, and patients’ preference. An adequate stability can be obtained by different plating techniques that have to be appropriately tailored to every single specific patient.

Abstract Purpose Our purpose was to compare the effects of piezosurgery and conventional rotary instruments on postoperative pain, swelling, trismus, and patients’ comfort after mandibular third molar surgery. Methods Thirty patients (27 women and 3 men) with bilateral impacted mandibular third molars were included in this split-mouth clinical study. Sixty impacted third molars were divided into a control group (n = 30), in which the osteotomies were performed using a conventional rotary handpiece technique and an experimental group (n = 30), in which the osteotomies were done by piezosurgery technique. Duration of the procedure was recorded. Postoperative pain was assessed using a visual analogue scale (VAS). All the patients were given a form containing verbal rating scale for evaluating the swelling. Trismus was evaluated using a caliper at maximum mouth opening (cm). In postoperative seventh day, patients were asked to fill a global quality of life (QoL) scale as well. Results There was no significant difference in postoperative pain, trismus, and swelling between control and experimental groups (p > 0.05). However, time of the procedure increased in control group (p < 0.05). Conclusion Piezosurgery is a safe way for performing the osteotomies during third molar surgery. However, regarding the postoperative morbidity, it does not have an advantage over conventional rotary instruments. Piezosurgery took longer to complete the osteotomy than the rotary handpiece technique.

Abstract Purpose The aim of this study was to perform a systematic review and meta-analysis to evaluate the efficacy of laser therapy on medication-related osteonecrosis of the jaw (MRONJ) treatment. Methods This study followed PRISMA standards, and an electronic search was performed on the PubMed/MEDLINE, Scopus, and Cochrane databases. Eighty-nine articles were found. After reading the manuscripts, 15 articles remained for the review. Three of them were selected for meta-analysis. Results Female gender was predominant (72.5%), and mean age was 66.5 years. Follow-up varied between 3 and 80 months, and the most used bisphosphonate was zoledronic acid (71.6%). Stage II of MRONJ was the most prevalent (68.9%), and the mandible was the most affected site (64.5%). Qualitative data showed that treatment with laser surgery (Er:YAG) was most effective regarding complete healing of the lesion (90%) compared with other treatments. Meta-analysis data showed that low-level laser therapy (LLLT) was more effective than medical treatment (P = 0.006), and surgical treatment was more effective than LLLT (P = 0.008). Conclusion Laser surgery was significantly superior to LLLT (p < 0.00001). Therefore, laser surgical therapy seems to be a great management strategy for MRONJ treatment from stage II. LLLT was shown to improve conservative management in earlier MRONJ stages.

Abstract Purpose In cases of highly atrophic alveolar ridges, augmentation procedures became a frequent procedure to gain optimal conditions for dental implants. Especially in the maxilla sinus floor elevation procedures represent the gold standard pre-prosthetic and mainly successful procedure. The perforation of the Schneiderian is one of the most common complications. The aim of this study was to evaluate whether the intraoperative perforation of the Schneiderian membrane has an impact on long-term implant success. Methods Thirty-four patients from a former study collective of the years 2005 and 2006 with a total of 41 perforations were invited for a follow-up examination to determine the long-term success rates after sinus floor elevation and subsequent implantation. Results Twenty-one patients with 25 perforations were subsequently re-evaluated. One implant was lost due to a of periimplant infection after 232 days, resulting in an implant survival rate of 98% within a mean follow-up period of 8.9 years (± 1.5 years). Conclusion Regarding the long-term success, there was no increased risk for implant failure or other persisting complications, e.g., sinusitis, after intraoperative perforation during sinus floor elevation in this study.