Oral and Maxillofacial Surgery

Abstract Purpose To evaluate the accuracy of three-dimensional (3D) soft tissue prediction in bimaxillary orthognathic surgery. Methods Cone-beam computed tomographs of 88 patients with class II (n = 46) and class III (n = 42) malocclusions, who underwent bimaxillary orthognathic surgery, were included in this retrospective study. 3D soft tissue prediction and postoperative outcome were compared by using ten landmarks of facial soft tissues. Patients’ sex and age were also assessed. Results were analyzed using a mixed model methodology (p < 0.05). Results The success criterion adopted was a mean discrepancy of < 2 mm. Most mandibular landmarks indicated a tendency for underprediction with a downward direction in class II patients, with some values > 2 mm. In class III, there was overprediction with a downward direction for the mandibular landmarks, with values < 2 mm. More accurate results were found in female and older patients. Conclusions 3D surgical planning showed clinically acceptable results for predicting soft tissues in patients undergoing bimaxillary orthognathic surgery, with more accurate results for class III patients. Although some differences were found when age and sex were interacted, a consistent association between these variables could not be stated. These results support the clinician, as accuracy can provide a strong guide to the surgeon when planning surgical orthodontic treatment.

Abstract Introduction Oropharyngeal cancer is characterized by high morbidity and mortality. Prognostic factors for this cancer are therefore useful to predict overall survival and may provide additional therapeutic targets. Objective To evaluate the 5-year overall survival and prognostic factors for oropharyngeal squamous cell carcinoma. Methods Retrospective cohort (2008–2018) of a cancer referral center. The population of the study was a hospital-based cohort consisting of patients diagnosed with oropharyngeal cancer who underwent surgery and/or adjuvant therapy (radio- and/or chemotherapy). Results A total of 253 patients with oropharyngeal squamous cell carcinoma were analyzed. The mean age was 59.8 ± 11.9 years and there was a male predominance (81.8%). Smoking and alcohol consumption were found in 88.0% and 84.2% of the sample, respectively. The combination of radiotherapy and chemotherapy was the treatment modality in 42.7% of the sample, followed by surgery combined with radio- and chemotherapy in 15.8%. There were 143 deaths (events), the mean survival was 11.55 ± 9.69 months, and the 5-year overall survival rate was 1.1%. Overall survival was lower for clinical stage III/IV (p < 0.001), HPV p16-negative status (p = 0.019), and an interval > 4 weeks between diagnosis and the beginning of treatment (p < 0.007). Conclusion Among the prognostic factors analyzed in this cohort, p16-negative status as a poor prognostic indicator and tumor stage III/IV and an interval longer than 4 weeks between diagnosis and the beginning of treatment were significantly associated with lower overall survival.

Abstract Purpose Recently we described mapping of the lingual nerve clinically in patients using electrical nerve stimulation. This paper reports results of a larger study with inter- and intra-observer reliability and comparison with positional measurements from magnetic resonance imaging (MRI). Methods In 50 healthy participants, measurements were taken when subjects felt a tingling sensation in the tongue induced by a stimulation probe over the lingual nerve. Three positions were measured in relation to the third molar. Measurement reliability was tested for both inter-observer and intra-observer agreement and positional data of the lingual nerve measured clinically was also compared with nerve position as measured from MRI scans. Results Out of 50 participants, 96 nerves (49 = left/47 = right) were included in the study. The lingual nerve was identified in 90% (87) of this sample. The mean of height of the nerve in points A, B and C were 9.64 mm, 10.77 mm and 12.34 respectively. Inter-and intra-observer agreement was considered to be good to excellent (ICC = 0.8–0.96). Agreement between nerve mapping measured values and MRI measured values was good (ICC < 0.6). Conclusion This technique may prove useful for the clinical determination of lingual nerve position prior to procedures in the third molar region.

Abstract Background and aims The replacement of teeth with osseointegrated implants is one of the significant advances in the field of restorative dentistry. The time interval between tooth extraction and the implant can be very short or long. This systematic review and meta-analysis aimed to collect and evaluate articles related to determining the effect of instant loading of dental implants are placed in the fresh socket initial stability on the clinical success of the implant compared to delay loading dental implants. Materials and methods In this study, all the available articles indexed in leading databases, including PubMed, ISI Web of Science, Embase, PsycINFO, PROSPERO, and Scopus, were searched. The full text of the articles meeting the primary criteria to be included in this research was obtained and appraised. Data of studies were extracted if they were scored as a high or moderate level of evidence. Results A total of 2258 published articles were found through electronic database searching. After screening the titles and abstracts, and full text of articles, 16 studies met the inclusion criteria and were included in the analysis. The results of this study revealed that regarding the success rate, although there was no significant difference between immediate and delayed of dental implants, immediate procedure showed a lower incidence of bone loss in single implants. Conclusion Based on the results of this study, immediate loading of dental implant, under certain conditions, is a successful treatment process and is effective in reducing treatment time. Thus, immediate loading represents a valid alternative to the traditional delayed loading rehabilitation.

Abstract Purpose Management of mandibular condylar fracture has invited a great deal of controversy in maxillofacial trauma care. In the orthopaedic literature, surgeons have exhaustively described the use of a ‘hematoma block’ technique during closed reduction (CR) of the ankle or other long bone fractures. Post-traumatic ankylosis of the temporomandibular joint (TMJ) is due to development and progression of the intra-articular hematoma. We improvised their technique for use during CR of mandibular condylar fractures. The desirable effects which can be achieved with our proposed ‘novel TMJ hematoma nerve block’ technique are evacuating the accumulated hematoma, blocking auriculotemporal and masseteric nerves which in turn causes relaxation of the lateral pterygoid muscle, all in all, favouring accurate anatomical reduction of the fracture. Method Thirteen patients with isolated unilateral condylar fractures were subjected to our new technique. The parameters assessed were the amount of hematoma evacuated, pain in TMJ region during reduction and postoperative anatomic reduction on cone beam computed tomography (CBCT). Results All the patients showed a significant reduction in pain and lowered post-reduction angulation between the proximal condylar and distal ramal segments. Conclusion Our technique is minimally invasive, safe, simple to perform, yielding excellent anatomic reduction of the fracture fragments.

Abstract Surgical approaches to the head and maxillofacial area have been described and modified by multiple authors throughout history. It was during nineteenth and twentieth century when most of the techniques evolved due to advances in anesthesia and antibiotic therapy. Currently, a myriad of surgical approaches are employed to gain access to the maxillofacial complex, with each of them having advantages and disadvantages. Although the approaches are presented in numerous textbooks and articles, few texts describe the circumstances or historical context under which they were developed. In a series of three articles, we will provide a historical perspective of the evolution of the most common surgical approaches to the head and face employed today. Descriptions contain advantages and disadvantages of the approaches and modifications are also provided. The purpose of the present article (2/3) is to review the approaches to the midface.

Abstract Purpose The aim of this paper is to describe active decompression and distraction sugosteogenesis as an alternative for the management of odontogenic cystic lesions. The technique, demographics, success rate, and complications will be presented. Patients and methods A retrospective case series study design was implemented. This included patients found in our database from 2015 to 2018 with a diagnosis of any odontogenic cyst, in whom active decompression with distraction sugosteogenesis was implemented. The patient’s medical history, demographics, radiographic characteristics of the cyst, technique/device employed, complications, and rate of success were recorded. Results The sample consisted of 10 patients, with a mean age of 19.6 years (range 14–34). Sixty percent of all cases occurred in male patients and 40% in females. Forty percent of cases were consistent with odontogenic keratocysts with all cysts presenting in the mandible. No maxillary cases were documented. Seventy percent of such lesions were unilocular and 30% multilocular. Cortical fenestration/perforation was documented in 30% of cases and 1 pathologic fracture was seen. Active decompression was performed for an average of 37 days (range 30–50 days). With this system, radiographic resolution occurred in 1–3 months in 50% of cases, 6–12 months in 30% of cases, and 12 months in 20% of cases. Mean follow-up was 24.3 months. No recurrence was documented. Complications included fistula development (2 cases), flap dehiscence (1 case), and the size of the intraoral unit. Conclusions This investigation reviewed the authors’ 5-year experience employing active decompression with distraction sugosteogenesis for the management of odontogenic cystic lesions and showed that this is a reliable alternative for the management of odontogenic cysts.

Abstract Background To evaluate and compare accuracy in position and inclination of a single-tooth implant placement using tooth-supported surgical drill guide (SDG) and surgical drill guide with implant insertion guide (SDIG) in fully digital workflow. Materials and methods Thirty partially single edentulous patients were recruited. After randomization, participants were divided into 2 groups equally. The first group underwent implant placement through SDG only, while the second group was subjected to SDIG. All procedure proceeded under a fully digital workflow as the combination of digital scanning from an intraoral scanner, 3D radiographic images from cone-beam computed tomography (CBCT), implant planning software, and a 3D manufacturing machine. A post-operative CBCT was performed to compare the deviations (7 parameters) between planned and actual implant positions. Results The mean global deviations at the shoulder and apex were 0.74 ± 0.36 and 1.29 ± 0.61 mm, respectively in the SDG group and 0.48 ± 0.22 mm and 0.71 ± 0.31 mm, respectively in the SDIG group. Likewise, the other parameters in the SDIG group showed fewer deviations than SDG for all measurements. Statistically significant differences were indicated by all parameters except for the horizontal deviation at the implant shoulder (p < .05). Conclusion In single-tooth implant placement with a tooth-supported guide using a computer-assisted (static) system with the SDIG could reduce deviations of actual implant position when compared with using SDG only. Besides, guided implant surgery by fully digital workflow is a practical procedure and provides precise implant position regarding the prosthetic-driven concept.

Abstract Objective Patient-specific implants (PSI) for cranioplasty are expensive, and cost remains the limiting factor in low- to middle-income countries. The authors describe a novel, reproducible and cost-effective method of designing prefabricated titanium PSI cranioplasty. Methods Ten patients from June 2018 to December 2020 were included in this retrospective study. A three-dimensional stereolithography model was made on a custom-built 3D printer with variable layer heights to produce efficient and accurate details. A certain amount of defect in the temporal region was left uncovered to avoid complications related to temporalis muscle dissection. The stereolithography model with a cranial defect was reconstructed with modelling wax. The wax model was scanned with a blue light visible scanner. The digital data was transferred to the milling machine (Jayon Surgical®, Kerala, India), where a 1-mm-thick sheet of titanium was milled according to the specifications. RFCC scoring system was used for assessing cosmetic outcome. Results The mean duration of the surgery was 56.50 min, SD = 14.916 min (range 45–75 min). In 9/10 patients, the RFCC score was 4 points. No other complications were found at a minimum follow-up of 18 months in all patients. The cost per patient was approximately 30,000 INR or 400 US dollars. The average time required for us to get the PSI ready for surgery was about 15 days. Conclusion The authors demonstrate a novel, cost-effective and reproducible method of PSI using titanium for cranioplasty.

Abstract Introduction Assaults inflicting penetrating head and neck trauma have potential for serious morbidity or mortality. This paper studies in-depth all cases treated at a level one trauma centre in the North East of England over 10 years. Methods All patients assaulted with sharp implements to the head and neck treated from 2010 to 2019 were identified using clinical codes. Results Retrospective data collection were as follows: 214 patients identified (189 male, 25 female). Average age was 31.5 years (range 3–80). The majority presented between 20:00 and 05:00. Knives were the commonest weapon. Fifty-two had scalp, 137 face and 69 neck injuries. Forty-eight percent had additional non-head and neck injuries. Eighty-six percent required admission, 16.6% to intensive care. Oral and maxillofacial and plastic surgeons provided most treatment. One hundred two required treatment under general and 96 local anaesthetic. Sixteen patients had significant vascular injury, 1 brachial plexus injury, 4 facial nerve injuries (of which 3 repaired) and one required parotid duct repair. Mean length of stay was 3.7 days. No mortality was recorded. Incidence significantly increased from 2010 to 2019. Conclusions Head and neck penetrating injuries occur frequently, often with other injuries and mainly in young males. Incidence of significant vascular or nerve injury was low. This study provides important data for those planning trauma services.

Abstract Purpose This study was conducted to elucidate volumetric data of mandibular condyles of orthognathic patients by analyzing cone beam computed tomography images based upon semiautomatic segmentation. Methods Cone beam computed tomography images of 87 patients with malocclusions were analyzed in this retrospective study. Patients were between 17 and 53 years old and diagnosed with Angle class I, II, or III malocclusion. By using the validated open-source software “ITK-SNAP,” the volumetric measurements of 174 mandibular condyles were performed. Volumetric analysis was performed according to intra-subject side differences by paired Student t test. In accordance to inter-subject side, gender, age and type of malocclusion differences bivariate analysis and ANOVA were applied. Results The mean volume for the right condyle was 1.378 ± 0.447 cm3, with a maximum of 2.379 cm3 and a minimum of 0.121 cm3. The mean volume for the left side was 1.435 ± 0.474 cm3, with a maximum of 3.264 cm3 and a minimum of 0.109 cm3. Bivariate analysis indicated a highly significant inter-subject difference between the volume of the left and right mandibular condyles (p < 0.01). Females had a significantly smaller condyle volume than males (p < 0.05 left condyle; p < 0.01 right condyle). Conclusion The fact that shape and volume of mandibular condyles show a high susceptibility to pathological alterations and particularly malocclusions makes a precise knowledge about volumetric changes indispensable. Our results show that significant inter-subject differences in condyle volume could be found with respect to the side and gender. Larger volumes could be assessed for the left condyle and for male patients.

Abstract The appropriate surgical management of early-stage oral tongue squamous cell carcinoma (OTSCC) remains a debated topic. The aim of this study is to investigate the role of the pre-treatment neutrophil to lymphocyte ratio (NLR) and tumor depth of invasion (DOI) in predicting the presence of occult neck metastases in early-stage OTSCC. A retrospective analysis of patients affected by early-stage (cT1-T2 cN0) OTSCC who were submitted to elective neck dissection (END) was performed. Tumors were classified retrospectively according to the 8th TNM classification, the DOI was assessed on the pre-operative magnetic resonance imaging, and the pre-treatment NLR was calculated for each patient. A logistic regression model to estimate the probability π (x) of cervical metastases by studying the NLR and DOI was carried out. Next, the correlation between the two variables, the NLR and DOI, was preliminarily studied. A cohort of 110 patients was analyzed (mean age, 62 years old; male to female ratio 1.2:1). The patients were staged as cT1 in 53 cases and cT2 in 57 cases. A DOI greater than 5.4 mm and a NLR greater than 2.93 are associated with an increased risk of presenting occult cervical metastases. Furthermore, the variables NLR and DOI are linearly associated with a positive correlation, proved by Spearman’s rank correlation coefficient rho of 0.64, with a unitary increase in the DOI of 1 mm directly associated with an increase of 0.47 in the NLR. The DOI and NLR can be effectively used to predict the occurrence of occult neck metastasis and therefore to plan an END in early-stage OTSCC.

Abstract Surgical approaches to the head and maxillofacial area have been described and modified by many authors throughout history. It was, however, during the nineteenth and twentieth centuries due in large part to improvements in the delivery of anesthesia and antibiotic therapy when most of the techniques were described. Currently, a myriad of surgical techniques are employed to access the maxillofacial complex with advantages and disadvantages for each one. Although each approach is described in many text and articles, few describe the circumstances or the historical context under which they were designed. In a series of three articles, a historical perspective will be provided on the evolution of some of the most commonly employed today. Descriptions will enumerate the advantages and disadvantages of as well as later modifications. The purpose of the present article (1/3) is to review the approaches to the head and upper face.

Abstract Purpose Identify the most common concomitant injuries associated with facial trauma, and compare the efficacy of various scoring systems in estimation of mortality risks in this category of patients. Methods The study evaluated patients with facial and concomitant injuries, who received the multidisciplinary treatment in a specialized trauma hospital. Values of New Injury Severity Score, Glasgow Coma Scale, Facial Injury Severity Scale, age, and length of hospital stay were statistically analysed to determine presence of relationships between these indicators and define factors that significantly associated with lethal outcome. Results During 6-year observation period, 719 patients were treated with multiple or combined maxillofacial trauma, brain injuries and polytrauma. Mainly with isolated midface bones (49.7%), pan-facial (34.6%), mandible (12.9%), and frontal bone and walls (2.8%) fractures. Mortality was (2.2%). The mortality rates in patients with severe pan-facial fractures were higher (p = 0.008) than in single anatomical area (6% vs 1.5%). Age, GCS, and NISS were the most reliable indicator of lethal outcome. Conclusion Age, Glasgow Coma Scale and New Injury Severity Score main factors, that predicts lethal outcome with high accuracy. New Injury Severity Score value ≥ 41 is a critical level for survival prognosis and should be considered in treatment planning and management of this category of patients.

Abstract We present a challenging case of HIV-related lymphangioma-like Kaposi sarcoma (LLKS) affecting the oral cavity. A 54-year-old Brazilian male patient was referred to our center complaining of bleeding lesions affecting the oral cavity for 2 months. Interestingly, these oral lesions were the first clinical manifestation of HIV infection. Clinically, multiple erythematous nodular and patch lesions were observed. An incisional biopsy was performed, revealing numerous microscopic angled and irregular vascular channels lined with flattened endothelial cells. More cellularized and solid areas consisting of more fusiform cells with little pleomorphism and with slit-like vascular channels were noted. Based on immunoreactivity for CD31, CD34, D2-40, and HHV-8, the final diagnosis was oral LLKS. Highly active antiretroviral therapy (HAART) was initiated with dolutegravir, tenofovir, and lamivudine. During follow-up, the patient showed KS metastases to other sites and a chemotherapeutic protocol was initiated. Regression of the oral lesion was clearly noted by the clinicians 1 year after the KS diagnosis. Dentists should be able to recognize systemic diseases that affect the oral cavity such as KS in order to make an early diagnosis of its oral manifestations and to implement effective therapeutic measures to ensure a better prognosis.

Abstract Purpose To compare the efficacy of dexamethasone when administered preoperatively through sublingual and intramuscular routes for evaluating the reduction in pain, swelling, and trismus after removal of impacted mandibular third molar. Methods The study was conducted on patients who required surgical removal of impacted mandibular third molars under local anesthesia. A total of 150 patients were considered for the study who were divided into two groups of 75 patients each. Patients in the sublingual group were administered with 2 ml of dexamethasone 8 mg along with 2 ml of normal saline through sublingual route and patients in the intramuscular group were administered with 2 ml of dexamethasone 8 mg through intramuscular route 1 h before the commencement of mandibular third molar surgery. The subjects of all two groups were evaluated for pain, swelling, and trismus on 1st, 3rd, and 7th postoperative days. Results Patients in the sublingual group had significantly less pain and increased mouth opening on 1st, 3rd, and 7th postoperative days when compared to patients in the intramuscular group (P < 0.05), while the amount of swelling in the sublingual group was significantly less only on the 3rd and 7th postoperative days when compared to patients in the intramuscular group (P < 0.05). Four patients in the sublingual group consumed one dose of paracetamol 500 mg as a rescue drug on the day of surgery. In the intramuscular group, 9 patients consumed one dose of the same rescue drug on the day of surgery and 11 patients consumed one dose of rescue drug both on the day of surgery and on the 1st postoperative day. Conclusion This study concludes that preoperative administration of dexamethasone 8 mg through sublingual route had better efficacy than intramuscular route in controlling pain, swelling and trismus after mandibular third molar surgery.

Abstract Purpose To evaluate the technical success of conventional TMJ arthrocentesis in cadavers, using the tragal-lateral canthus line as an anatomical reference for the puncture points. Methods Ten formalin-treated and 8 fresh cadavers were submitted to the arthrocentesis. A point located 10 mm anteriorly and 2 mm inferiorly to the beginning of the tragal-lateral canthus line (A) and another point 20 mm anteriorly and 10 mm inferiorly (B) were demarked on the cadavers’ skin. Following, 1 mL of methylene blue solution was injected through the needle at point A, and then another needle was placed at point B. Saline solution was injected through the first needle, identifying a free flow of bluish solution. Results Concerning the formalin-treated cadavers, TMJ arthrocentesis was not successfully performed in any case (0%). In the fresh cadavers, the procedure was properly conducted bilaterally in only one case (12.5%) and unilaterally in 3 cases (37.5%), 2 on the left side (25.0%) and one on the right (12.5%). Conclusion The traditional points related to the tragal-lateral canthus line seemed not to be accurate references for the insertion of the needles in conventional TMJ arthrocentesis when 1 mL of solution is used initially and the maximum mouth opening is not achieved.

Abstract Purpose Adjuvant corticosteroid administration through local routes has gained popularity due to ease of technique, lesser morbidity and presumed advantage of achieving therapeutic dosage at the site. To evaluate this, present study has compared submucosal route with an intravenous route control using single-dose preoperative dexamethasone. The study investigated objective facial measurements, mouth opening and compared them with subjective scores on a visual analogue scale and quality of life (QOL) recovery questionnaire. Materials and methods This was a prospective, randomized, open-label study with blinded end-point assessment of submucosal and intravenous routes of single preoperative dexamethasone administration, in patients undergoing mandibular third molar surgery. Patients were randomly divided into two groups and received 8 mg DX as either submucosal or intravenous injection 5 min after administration of local anaesthesia. Data was collected at 2nd and 7th post-op intervals. Statistical analysis was done keeping a P value < 0.05 as significant. Results Thirty patients were evaluated in the study. SM route behaved similarly to IV route in producing changes in facial measurements [P = 0.533], mouth opening [P = 0.533] and pain [VAS] scores [P = 0.533] at early and late intervals. Questionnaire subscale scores were not significantly different between groups, but total mean score was significant [P = 0.050] with a measure of variance 17.54 in group IV compared with 39.54 of group SM showing that subjectively, IV route brought better recovery. Conclusion and clinical relevance Submucosal route can be an effective less invasive, painless, straightforward alternative to systemic administration of corticosteroid for improving QOL recovery in mandibular third molar surgery.

Abstract This systematic review analysed evidence relating to medication-related osteonecrosis of the jaws (MRONJ) associated with protein kinase inhibitors in antiresorptive naïve patients. A literature search of major biomedical databases was conducted in March 2020. Information extracted from relevant articles included bibliographic information, patient characteristics, MRONJ characteristics at diagnosis, management strategies and outcomes. Sixteen studies, representing data from 17 patients, were included for final analysis. Descriptive statistics were used to synthesis available data. Eleven protein kinase inhibitors were implicated, with a mean exposure of 13 months prior to MRONJ. Renal cell carcinoma was the primary diagnosis in 41.2% of patients. Patient symptoms, clinical features, radiographic findings and histological findings were consistent with those previously described in patients with MRONJ associated with antiresorptive medications. Overall, there was a 75% rate of cure, with a mean healing time of 17.2 weeks. Patients were treated surgically in 53.3% of the cases. Patients treated surgically achieved complete healing in 100% of cases, compared with 58% in those treated conservatively. Drug discontinuation was reported in 69.2% of patients. Patients who had the offending drug discontinued achieved complete healing in 75% of cases, compared with 50% in those who did not. Evidence relating to MRONJ associated with protein kinase inhibitors is of low quality. From the available data, there are notable differences relating to patient characteristics, treatment strategies and outcomes, between MRONJ associated with protein kinase inhibitors compared with antiresorptives. Higher quality evidence is required to support the findings of this review.

Abstract Le Fort I osteotomy is the most common procedure for maxillary advancement in cleft patients, and a significant relapse is expected in the postoperative period. This study purpose is to evaluate the maxillary relapse and associated factors in cleft lip and palate (CLP) patients submitted to standard Le Fort I advancement. This systematic review sought studies in PubMed, SCOPUS, and Cochrane and included papers that evaluated the maxillary relapse with at least 1-year postoperative period. The quality assessment was adapted following PRISMA statement. The initial electronic search found 345 papers, and the final selection included 10 studies. In total, 275 CLP patients were evaluated 198 had unilateral CLP and 41 had bilateral CLP. Isolated maxillary advancement was performed in 166 patients, while 109 had bimaxillary surgery. The mean relapse in horizontal and vertical plane was 1.2 mm (19.7%) and 1.0 mm (29.4%), respectively. In conclusion, a relapse after maxillary advancement in patients with CLP is expected, being higher in vertical plane. Patients with UCLP and those who underwent bimaxillary surgery had a higher relapse rate. Due to the miscellaneous data and methodologies, future prospective clinical trials should apply rigorous selection of CLP patients sample and methods for variable analysis to obtain more accurate results.