Antibiotic susceptibility and genome analysis of Enterococcus species isolated from inpatients in one hospital with no apparent outbreak of vancomycin-resistant Enterococcus in Japan.

To prevent nosocomial infection, it is important to screen for potential vancomycin-resistant Enterococcus (VRE) among patients. In this study, we analyzed enterococcal isolates from inpatients in one hospital without any apparent outbreak of VRE. Enterococcal isolates were collected from inpatients at Hiroshima University Hospital from April 1 to June 30, 2021 using selective medium for Enterococci. Multilocus sequence typing, antimicrobial susceptibility testing, and whole-genome sequencing were performed. A total of 164 isolates, including Enterococcus faecium (41 isolates), Enterococcus faecalis (80 isolates), Enterococcus raffinosus (11 isolates), Enterococcus casseliflavus (nine isolates), Enterococcus avium (12 isolates), Enterococcus lactis (eight isolates), Enterococcus gallinarum (two isolates), and Enterococcus malodoratus (one isolate), were analyzed. We found one vanA-positive E. faecium, which was already informed when the patient was transferred to the hospital, nine vanC-positive E. casseliflavus, and two vanC-positive E. gallinarum. E. faecium isolates showed resistance to ampicillin (95.1%), imipenem (95.1%), and levofloxacin (87.8%), and E. faecalis isolates showed resistance to minocycline (49.4%). Ampicillin- and levofloxacin-resistant E. faecium had multiple mutations in penicillin-binding protein 5 (PBP5) (39/39 isolates) and ParC/GyrA (21/36 isolates), respectively. E. raffinosus showed resistance to ampicillin (81.8%), imipenem (45.5%), and levofloxacin (45.5%), and E. lactis showed resistance to ampicillin (37.5%) and imipenem (50.0%). The linezolid resistance genes optrA and cfr(B) were found only in one isolate of E. faecalis and E. raffinosus, respectively. This study, showing the status of enterococci infection in hospitalized patients, is one of the important information when considering nosocomial infection control of VRE.

Chemical inhibition of LSD1 leads to epithelial to mesenchymal transition in vitro of an oral squamous cell carcinoma OM-1 cell line via release from LSD1-dependent suppression of ZEB1.

The epigenetic regulation for gene expression determines cell plasticity. Oral squamous cell carcinoma (SCC) exhibits bidirectional cell plasticity, i.e. epithelial differentiation and epithelial to mesenchymal transition (EMT). The epigenetic regulator LSD1 is a histone H3-specific demethylase to which chemical inhibitors for its activity had been developed as an anti-cancer therapeutics. The bidirectional plasticity of the oral SCC cell line OM-1 had been characterized, but it remained unclear how chemical LSD1 inhibitors affect cell plasticity. Here we reported an adverse effect against cancer therapeutics, which was EMT induction in vitro by the chemical LSD1 inhibitor. The LSD1 inhibitor caused EMT-TF ZEB1 in OM-1 to undergo EMT. Furthermore, an additional EMT-TF Snail-dependent partial EMT phenotype in OM-1 progressed to complete EMT in conjunction with LSD1 inhibitor-dependent ZEB1 induction. The promotor activity of ZEB1 was up-regulated under LSD1 inhibition. The regulatory chromatin regions of ZEB1 accumulated histone H3 methylation under the chemical inhibition of LSD1. The LSD1 inhibitor also upregulates epithelial gene expression in vitro; however, the bidirectional effect of LSD1 inhibitor should be considered in cancer therapeutics.

ACE2 expression and spike S1 protein-mediated immune responses in oral mucosal cells.

OBJECTIVES: ACE2, known as a host receptor involved with SARS-CoV-2 infection, binds to viral spike proteins for host cell entry. However, details regarding its induction and function in oral mucosal cells remain unknown. MATERIALS AND METHODS: We examined ACE2 expression and its induction by transfected mimic nucleotides and pro-inflammatory cytokines in oral keratinocytes (RT7) and fibroblasts (GT1). Subsequently, the effects of viral spike S1 protein via ACE2 on CXCL10 expression induced by pro-inflammatory cytokines in both cells were examined. RESULTS: ACE2 was constitutively expressed in RT7 and GT1. Transfected Poly(I:C) and Poly(dA:dT) increased ACE2 expression in those cells, while knockdown of RIG-I decreased ACE2 expression induced by those transfected ds nucleotides. IFN-γ and TNF-α enhanced transfected ds nucleotides-induced ACE2 expression in RT7 but not GT1. S1 protein alone did not affect CXCL10 expression in either cell type, whereas it enhanced IFN-ß-induced CXCL10 in both, while immune responses of IFN-γ- and TNF-α-induced CXCL10 enhanced by S1 protein were different between RT7 and GT1. Finally, knockdown of ACE2 decreased cytokines and S1 protein mediated-CXCL10 levels in both cells. CONCLUSIONS: ACE2 in oral mucosal cells may contribute to development of infection and inflammation in cooperation with pro-inflammatory cytokines following SARS-CoV-2 invasion.

Efficacy and safety of remimazolam besilate for sedation in outpatients undergoing impacted third molar extraction: a prospective exploratory study.

BACKGROUND: Dental treatments often cause anxiety, fear, and stress in patients. Intravenous sedation is widely used to alleviate these concerns, and various agents are employed for sedation. However, it is important to find safer and more effective sedation agents, considering the adverse effects associated with current agents. This study aimed to investigate the efficacy and safety of remimazolam besilate (hereinafter called "remimazolam") and to determine the optimal dosages for sedation in outpatients undergoing dental procedures. METHODS: Thirty-one outpatients aged 18-65 years scheduled for impacted third molar extraction were included in the study. Remimazolam was administered as a single dose of 0.05 mg/kg followed by a continuous infusion at a rate of 0.35 mg/kg/h, with the infusion rate adjusted to maintain a sedation level at a Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2-4. The primary endpoint was the sedation success rate with remimazolam monotherapy, and the secondary endpoints included induction time, recovery time, time until discharge, remimazolam dose, respiratory and circulatory dynamics, and frequency of adverse events. RESULTS: The sedation success rate with remimazolam monotherapy was 100%. The remimazolam induction dose was 0.08 (0.07-0.09) mg/kg, and the anesthesia induction time was 3.2 (2.6-3.9) min. The mean infusion rate of remimazolam during the procedure was 0.40 (0.38-0.42) mg/kg/h. The time from the end of remimazolam administration to awakening was 8.0 (6.7-9.3) min, and the time from the end of remimazolam administration to discharge was 14.0 (12.5-15.5) min. There were no significant respiratory or circulatory effects requiring intervention during sedation. CONCLUSIONS: Continuous intravenous administration of remimazolam can achieve optimal sedation levels without significantly affecting respiratory or circulatory dynamics. The study also provided guidance on the appropriate dosage of remimazolam for achieving moderate sedation during dental procedures. Additionally, the study findings suggest that electroencephalogram monitoring can be a reliable indicator of the level of sedation during dental procedural sedation with remimazolam. TRIAL REGISTRATION: The study was registered in the Japan Registry of Clinical Trials (No. jRCTs061220052) on 30/08/2022.

Sunitinib promotes apoptosis via p38 MAPK activation and STAT3 downregulation in oral keratinocytes.

OBJECTIVE: Sunitinib, a targeted cancer drug, inhibits tyrosine kinases receptors and is widely used as first-line treatment for metastatic renal cell carcinoma. Patients undergoing chemotherapy with sunitinib frequently have oral mucosal complications, such as oral stomatitis, though cytotoxic effects of the drug on oral keratinocytes remain unknown. METHODS: The effects of sunitinib on immortalized oral keratinocytes, RT7 cells, in regard to cell injury and apoptosis, as well as apoptosis-mediated signaling pathways were investigated. RESULTS: Sunitinib treatment caused a significant increase in lactate dehydrogenase (LDH) in RT7 cells and primary oral keratinocytes. Additionally, the drug induced apoptosis-related events, such as DNA fragmentation, decreased anti-apoptotic Bcl-2 protein expression, and induction of cleaved PARP and caspase 3/9 in RT7 cells. Furthermore, phosphorylation of p38 MAPK, but not of ERK or JNK, was increased. On the contrary, constitutive phosphorylated STAT3 was decreased by sunitinib treatment, which was recovered by exposure to SB203580, a p38 MAPK inhibitor. Finally, SB203580 was found to reduce sunitinib-induced cell injury and apoptosis. CONCLUSION: The present results indicate that sunitinib promotes cell injury and apoptosis in oral keratinocytes via p38 activation and STAT3 downregulation. Sunitinib-mediated oral complications may be associated with cytotoxic effects of the drug on oral keratinocytes.

Indian hedgehog in craniofacial neural crest cells links to skeletal malocclusion by regulating associated cartilage formation and gene expression.

The frontal craniofacial skeleton derived from neural crest cells is vital for facial structure and masticatory functions. The exact role of Indian hedgehog (Ihh) in facial and masticatory development has not been fully explored. In this study, we generated craniofacial neural crest cells-specific Ihh deletion mice (Wnt1-Cre;Ihhfl/fl ;Tomatofl/+ ) and found the gradual dwarfism without perinatal lethality. Morphological and histological analyses revealed unambiguous craniofacial phenotypes in mutants, where we observed skeletal malocclusion accompanied by markedly hypoplastic nasomaxillary complex and reversed incisor occlusion. Both the replacement of nasal concha cartilage by turbinate bones and the endochondral ossification of nasal septum ethmoid bone were substantially delayed. We also observed hypoplastic mandibles in mutants where the mandibular ramus was unexpectedly the most affected. Both the condylar process and mandibular angle cartilages were distorted. However, dental examination showed no significant changes in teeth and dentition. Finally, a comprehensive RNA sequence analysis utilizing condylar cartilage identified Ihh-associated gene network including several cell cycle genes and 16 genes related to the extracellular matrix, sulfate transporters, transcription factors, receptors, a ciliogenesis factor, and an adhesion molecule. Our data provide direct in vivo evidence that Ihh plays crucial roles in midface and masticatory system formation, likely by activating key genes.

A Multicenter Retrospective Study of Elective Neck Dissection for T1-2N0M0 Tongue Squamous Cell Carcinoma: Analysis Using Propensity Score-Matching.

BACKGROUND: This multicenter retrospective study aimed to determine whether elective neck dissection (END) can be performed for T1-2N0M0 tongue cancer. METHODS: Patients with T1-2N0M0 tongue squamous cell carcinoma who received treatment between January 2000 and December 2012 were enrolled at 14 multicenter study sites. The 5-year overall survival (OS) and 5-year disease-specific survival (DSS) were compared between the propensity score-matched END and observation (OBS) groups. RESULTS: The results showed that the OS rates among the 1234 enrolled patients were 85.5% in the END group and 90.2% in the OBS group (P = 0.182). The DSS rates were 87.0% in the END group and 94.3% in the OBS group (P = 0.003). Among the matched patients, the OS rates were 87.1% in the END group and 76.2% in the OBS group (P = 0.0051), and the respective DSS rates were 89.2% and 82.2% (P = 0.0335). CONCLUSION: This study showed that END is beneficial for T1-2N0M0 tongue cancer. However, END should be performed for patients with a tumor depth of 4-5 mm or more, which is the depth associated with a high rate of lymph node metastasis. The use of END should be carefully considered for both elderly and young patients.

Tumor budding and adjacent tissue at the invasive front correlate with delayed neck metastasis in clinical early-stage tongue squamous cell carcinoma.

BACKGROUND AND OBJECTIVES: Some patients with early-stage oral cancer have a poor prognosis owing to the delayed neck metastasis (DNM). Tumor budding is reportedly a promising prognostic marker in many cancers. Moreover, the tissue surrounding a tumor is also considered to play a prognostic role. In this study, we evaluated whether tumor budding and adjacent tissue at the invasive front can be potential novel predictors of DNM in early tongue cancer. METHODS: In total, 337 patients with early-stage tongue squamous cell carcinoma were retrospectively reviewed. The patient characteristics and histopathological factors were evaluated for association with DNM. DNM rates were calculated; items which were significant in the univariate analysis were used as explanatory variables, and independent factors for DNM were identified by the multivariate analysis. RESULTS: The univariate analysis identified T classification, depth of invasion, tumor budding, vascular invasion, and adjacent tissue at the invasive front as significant predictors of DNM; the multivariate analysis using these factors revealed all the above variables except vascular invasion, which are independent predictors of DNM. CONCLUSION: In addition to conventional predictors, high grade tumor budding and adjacent tissue at the invasive front can serve as useful predictors of DNM in early tongue cancer.

Performance status scale for head and neck scores for oral cancer survivors: predictors and factors for improving quality of life.

OBJECTIVES: This study aimed to determine the factors associated with long-term quality of life of oral cancer survivors. MATERIALS AND METHODS: A total of 508 survivors were assessed using the performance status scale for head and neck (PSS-HN), which comprises Eating in Public (E-Public), Normalcy of Diet (N-Diet), and Understandability of Speech (U-Speech). Stepwise multiple linear regression analysis was performed. RESULTS: The median time between the end of treatment and participating in the survey was 38 months (range, 6-250). Overall, 57-60% of survivors achieved full performance (100 score) of each PSS-HN score, whereas 15% had moderate or severe impairment (≤ 50 score) in E-Public and N-Diet, and 4% had impairment in U-Speech. These three scores deteriorated with increasing T-stage. Age, soft tissue reconstruction, trismus, and missing occlusal contacts on the contralateral side were significantly associated with E-Public and N-Diet. Neck dissection, hard tissue reconstruction, and missing occlusal contacts bilaterally were associated with U-Speech score. CONCLUSION: Older age, T4 tumor, and soft tissue reconstruction were predictors of low E-Public and N-Diet performance scores. Increasing mouth opening and maintaining optimal occlusal contacts on the contralateral side may be effective ways to improve N-Diet and E-Public performance. Maintaining optimal occlusal contacts bilaterally may be effective for improving speech performance. CLINICAL RELEVANCE: Oral health care to increase optimal occlusal contacts and rehabilitation of trismus may be promising factors to improve the functional performance of oral cancer survivors.

Orthodontic-Surgical Approach for Treating Skeletal Class III Malocclusion With Severe Maxillary Deficiency in Isolated Cleft Palate.

Orthodontic treatment in patients with orofacial cleft such as cleft lip and palate or isolated cleft palate is challenging, especially when the patients exhibit severe maxillary growth retardation. To correct this deficiency, maxillary expansion and protraction can be performed in the first phase of orthodontic treatment. However, in some cases, the malocclusion cannot be corrected by these procedures, and thus, skeletal discrepancy remains when the patients are adolescents. These remaining problems occasionally require various orthognathic treatments according to the degree of the discrepancy. Here, we describe one case of a female with isolated cleft palate and hand malformation who exhibited severe maxillary deficiency until her adolescence and was treated with multiple orthognathic surgeries, including surgically assisted maxillary expansion (surgically assisted rapid palatal expansion), LeFort I osteotomy, and bilateral sagittal split osteotomy in order to correct severe skeletal discrepancy and malocclusion. The treatment resulted in balanced facial appearance and mutually protected occlusion with good stability. The purpose of this case report is to show the orthodontic treatment outcome of 1 patient who exhibited isolated cleft palate and subsequent severe skeletal deformities and malocclusion which was treated by an orthodontic-surgical approach.

The Elimination of Dental Crowding and Development of a Proper Dental Arch by Maxillary Anterior Segmental Distraction Osteogenesis for a Patient With UCLP.

OBJECTIVE: This report describes the case of a male patient with a complete unilateral cleft lip and palate who presented with midface deficiency and an anteroposteriorly constricted maxilla. DESIGN: Case report Interventions: Correction involved anterior distraction of the segmented maxilla. RESULTS: The present case demonstrates that elongation of the maxilla with anterior distraction is an effective way to develop a proper dental arch, correct anterior and posterior crowding, and improve a midface deficiency.

Significant prognostic factors affecting treatment outcomes of salivary gland carcinoma: a multicenter retrospective analysis.

The purpose of this study was to investigate the prognostic factor in salivary gland carcinoma patients. Clinical and pathological data of 211 consecutive patients who treated with curative intent were analyzed. The overall survival (OS) rate, local control rate, and distant metastasis rate were calculated. To examine a prognostic factor in salivary gland carcinoma patients, a multivariate analysis was performed. The 5-year-OS rate was 84.0%, and 10-year was 69.2%. The 5-year-local control rate was 84.6%, and 10-year was 70.1%. The 5-year-distant metastasis rate was 16.9%, and 10-year was 21.1%. In a multivariate analysis, the OS rate was affected by pN(+), high-grade malignancy, and primary tumor size. The local control was affected by the primary tumor size, high-grade malignancy, and the status of the surgical margin. The primary tumor size and pN(+) were associated with the distant metastasis. The results of this study suggested that pN(+), malignancy grade, primary tumor size, and the margin status might affect the prognosis of salivary gland carcinoma patients. Postoperative radiotherapy and adjuvant chemotherapy were suggested the possibility of contribution to the good prognosis of salivary gland carcinoma patients.

Efficacy of Maxillary Anterior Segmental Distraction Osteogenesis in Patients With Cleft Lip and Palate.

OBJECTIVES: To evaluate the effects of maxillary anterior segmental distraction osteogenesis (MASDO) in patients with cleft lip and palate (CLP) and to identify risk factors for increased relapse. DESIGN: A retrospective study. PATIENTS: Thirty-one Japanese patients with CLP who underwent MASDO were eligible for study inclusion. MAIN OUTCOME MEASURES: We evaluated lateral cephalograms obtained before (T1), at 3 months (T2), and at 1 year (T3) after MASDO, and measured changes from T1 to T2 (δT1T2), from T2 to T3 (δT2T3), and from T1 to T3 (δT1T3). We also evaluated the risk factors associated with an increased relapse. RESULTS: Overall (δT1T3), MASDO improved retrusion of the maxilla. We measured a significant advancement (6.1 mm) of the anterior maxillary segment in δT1T2 (A-McNamara classification) and increases in the overjet and the SNA, ANB, and nasolabial angles. However, skeletal relapse was evident in δT2T3, and the median percentage of relapse was 10%. To explore the risk factors, we subdivided patients with a δT1T2 of >5 mm into 2 groups based on the percentage of relapse (>15% vs ≤15%). There were significant differences between these groups in the vertical positions of the anterior nasal spine and point A, and the angle formed by the SN and palatal planes (SNPP), suggestive of intraoperative counterclockwise rotation of the maxilla. CONCLUSIONS: MASDO is effective for correcting midfacial deficiencies, but counterclockwise rotation of the maxilla during surgery may cause relapse.

Clinical investigation of 38 cases of oral mucosal melanoma: A multicentre retrospective analysis in Japan.

BACKGROUND/OBJECTIVES: The aim of the present study was to investigate treatment modalities and outcomes in oral mucosal melanoma. METHODS: The clinical and pathological data of 38 consecutive patients with oral mucosal melanoma were retrospectively analyzed. Patients' characteristics were analyzed and overall survival (OS) rates were calculated. RESULTS: Sixteen patients had stage III (42%), 19 IVA (50%), and three had stage IVC (8%) disease. Among the therapeutic approaches used, 31 patients (82%) received radical therapy (surgery +/- chemotherapy). The 5-year OS rate was 40%. Five-year OS rates according to the clinical stage were 71% for stage III, 24% for stage IVA, and 0% for stage IVC. Five-year OS rates according to therapeutic approaches were 52% in the radical therapy group and 0% in the palliative therapy and best supportive care groups. CONCLUSIONS: The results of this multicentre retrospective analysis of patients with oral mucosal melanoma suggest that radical therapy based on surgical treatments with complete surgical excision with clear margins leads to a better prognosis.

Maxillary Anterior Segmental Distraction Osteogenesis to Correct Maxillary Deficiencies in a Patient With Cleft Lip and Palate.

This report describes a case of successful orthodontic treatment using maxillary anterior segmental distraction osteogenesis with an internal maxillary distractor and bilateral sagittal split ramus osteotomy in a girl with cleft lip and palate. A 16-year-old girl with unilateral cleft lip and palate exhibited midface retrusion because of growth inhibition of the maxillary complex and mandibular excess. After the presurgical orthodontic treatment, 6.0-mm advancement of the maxillary anterior segment and 4.0-mm set back of the mandible were performed. After a retention period, the patient's midface convexity was greatly improved and the velopharyngeal competence was preserved without relapse.

Asymmetric Anterior Distraction for Transversely Distorted Maxilla and Midfacial Anteroposterior Deficiency in a Patient With Cleft Lip/Palate: Two-Stage Surgical Approach.

The present report describes a male patient with a unilateral cleft lip and palate who presented with midfacial anteroposterior and transverse deficiency. Correction involved a two-stage surgical-orthodontic approach: asymmetric anterior distraction of the segmented maxilla followed by two-jaw surgery (LeFort I and bilateral sagittal splitting ramus osteotomies). The present case demonstrates that the asymmetric elongation of the maxilla with anterior distraction is an effective way to correct a transversely distorted alveolar form and midfacial anteroposterior deficiency. Furthermore, successful tooth movement was demonstrated in the new bone created by distraction.

Multicenter Retrospective Study of Adjuvant Therapy for Patients with Pathologically Lymph Node-Positive Oral Squamous Cell Carcinoma: Analysis of Covariance Using Propensity Score.

BACKGROUND: The presence of pathologically positive lymph nodes (pN+) is a well-known prognostic factor in oral squamous cell carcinoma (OSCC). The aims of this retrospective multicenter study were to assess the prognosis of OSCC patients with pN+ disease; to compare the prognosis of patients with pN+ disease who underwent surgery plus radiotherapy (RT) or concurrent chemoradiotherapy (CCRT) with that of patients who underwent surgery only; and to account for biases associated with treatment selection of adjuvant RT or CCRT. METHODS: The records of 313 OSCC patients with pN+ disease were retrospectively reviewed. The main outcome measures were 5-year disease-specific survival (DSS) and overall survival (OS) rates. To reduce selection biases associated with retrospective data, the treatment groups were evaluated by Cox proportional hazard analysis with propensity score as a covariate. RESULTS: The 5-year OS and DSS survival rates for the entire patient cohort were 51.8 and 59.2 %, respectively. T3-4 stage, closed (<5 mm) margin distance, ≥4 involved nodes, and extracapsular spread were significant poor prognostic factors for OS and DSS. In the propensity score analysis, postoperative RT/CCRT significantly improved OS and DSS compared to surgery only. However, OS and DSS were not significantly different between patients who received postoperative RT and CCRT. CONCLUSION: The addition of cytotoxic chemotherapy to RT does not provide additional survival benefit in OSCC patients with pN+ disease. Alternative strategies, such as molecular targeted therapies, are needed to further improve the survival of high-risk OSCC patients with pN+ disease.

Maxillary Expansion and Midline Correction by Asymmetric Transverse Distraction Osteogenesis in a Patient With Unilateral Cleft Lip/Palate: A Case Report.

This case report presents the management of a female patient with unilateral cleft lip and palate presenting with skeletal Class III malocclusion and a narrow upper dental arch with a midline deviation. The treatment plan involved asymmetric transverse distraction osteogenesis of the maxilla to make the upper dental midline coincident with the facial midline. After the treatment, a good facial profile and a close intercuspation of teeth were achieved. Occlusion remained stable with normal overjet and overbite after 2-year retention.

Surgical Orthodontic Treatment for Skeletal Maxillary Protrusion in Sturge-Weber Syndrome: A Case Report and Review of the Literature.

Sturge-Weber syndrome (SWS) is characterized by hemangiomas, glaucoma, and central nervous system disorders. Here, we report the case of a 15-year-old boy with SWS and upper-lip hypertrophy who underwent surgical orthodontic treatment for correction of a large overjet and deep overbite. In addition to the a large overjet and deep overbite, interdental spacing was observed in both the arches. The mandible was retrognathic and deviated to the right side. No maxillary occlusal canting or temporomandibular joint symptoms were observed. The patient was diagnosed with skeletal maxillary protrusion with spaced dentition and mandibular deviation to the right due to SWS. After presurgical orthodontic treatment using a multibracket appliance, we performed a sagittal split ramus osteotomy (SSRO) alone due to the presence of a hemangioma around the maxilla. No abnormal bleeding or cerebral hemorrhage due to increased blood pressure was observed during the SSRO. Postoperatively, the maxillary and mandibular arches were well-aligned, the deep overbite and excessive overjet improved, and bilateral angle class I molar and canine relationships were established. Furthermore, mandibular deviation improved, and the midlines of both arches approximately coincided with the facial midline. In conclusion, orthognathic surgery is feasible in patients with SWS after carefully evaluating the sites and sizes of the hemangiomas.

Anesthetic management of a patient with Sturge-Weber syndrome in sagittal split ramus osteotomy surgery.

Sturge-Weber syndrome (SWS) is a neurocutaneous syndrome characterized by angiomas. This report presents airway management using submental intubation in sagittal split ramus osteotomy under general anesthesia and aimed to explore better anesthetic management for avoiding the rupture of angiomas in a patient with SWS.