Facial Asymmetry Caused by Mandibular Condylar Hyperplasia: A Two Center Study.

BACKGROUND: Condylar hyperplasia is a non-neoplastic overgrowth of the mandibular condyle. The disorder is progressive and causes gradual jaw deviation, facial asymmetry, and dental malocclusion. The only treatment capable of stopping hyperplastic growth is surgical condylectomy to remove the upper portion of the condyle containing the deranged growth center. When this procedure is conducted in proportion to the length of the healthy side it may also correct the jaw deviation and facial asymmetry. OBJECTIVES: To assess the degree to which condylectomy corrects the asymmetry and to determine the proportion of patients after condylectomy who were satisfied with the esthetic result and did not desire further corrective surgery. METHODS: We conducted a retrospective analysis of medical records of patients who underwent condylectomy that was not followed by corrective orthognathic surgery for at least 1 year to determine the degree of correction of chin deviation and lip cant. Patient satisfaction from treatment or desire and undergo further corrective surgery was reported. RESULTS: Chin deviation decreased after condylectomy from a mean of 4.8° to a mean of 1.8° (P < 0.001). Lip cant decreased after condylectomy from a mean of 3.5° to a mean of 1.5° (P < 0.001). Most patients (72%) were satisfied with the results and did not consider further corrective orthognathic surgery. CONCLUSIONS: Proportional condylectomy could be a viable treatment to both arrest the condylar overgrowth and achieve some correction of the facial asymmetry.

Can Condylectomy Alone Achieve Facial Symmetry in Patients With Hemimandibular Hyperplasia (Condylar Hyperplasia Type 2)?

The purpose of the present study was to evaluate the 3-dimensional orofacial changes occurring after proportional condylectomy in patients with unilateral condylar hyperplasia type 2 (hemimandibular hyperplasia). Eight patients underwent proportional condylectomy that was not followed by orthognathic surgery or orthodontic treatment for at least 1 year. The precondylectomy and postcondylectomy photographs and radiographs were analyzed cephalometrically and compared. The average length of the condylar segment removed was 13 mm and this resulted in almost equal heights of the ramus-condyle units of both sides. Evaluations in the vertical plane improved after surgery; however, when the preoperative asymmetry was significant, the residual asymmetry continued to be notable after condylectomy. Transverse plane evaluations improved after condylectomy, and chin position was satisfactorily centralized in all patients. In the horizontal plane, mandibular setback occurred, and this was considered favorable when the preoperative skeletal profile was class III, whereas the opposite was when the patient was class I before surgery. The occlusion improved gradually over the postoperative months by the intrusion on the affected side and extrusion on the unaffected side into a bilaterally balanced posterior contacts with residual anterior open bite. In conclusion, condylar hyperplasia type 2 patients with mild asymmetry and low esthetic demands can benefit from proportional condylectomy as the sole treatment to both stop the hyperplastic condylar growth and improve the asymmetry to some extent. Surgeons should be able to predict the change that is expected to occur after proportional condylectomy and discuss this with the patient before surgery.

Headache Attributed to Temporomandibular Disorders: Axis I and II Findings According to the Diagnostic Criteria for Temporomandibular Disorders.

AIMS: To analyze Axis I and II findings of patients diagnosed as having painful temporomandibular disorder (TMD) with headache attributed to TMD (HAattrTMD) in order to assess whether HAattrTMD is associated with a specific Axis I and II profile suggestive of the central sensitization process. METHODS: This retrospective study included 220 patients with painful TMD divided into those with (n = 60) and those without (n = 160) HAattrTMD, and the patients were compared for Axis I and II results according to the Diagnostic Criteria for TMD (DC/TMD). A P value < .05 was considered statistically significant. RESULTS: A total of 27.3% of the patients received a diagnosis of HAattrTMD. Myofascial pain with referral was significantly more common in the HAattrTMD group (P < .001), while local myalgia was significantly more common in the non-HAattrTMD group (P < .001). Characteristic pain intensity was significantly higher in the HAattrTMD group (P = .003), which also showed significantly higher levels of depression (P = .002), nonspecific physical symptoms (P = .004), graded chronic pain (P = .008), and pain catastrophizing (P = .013). Nonspecific physical symptoms were positively associated with HAattrTMD (odds ratio [OR] = 1.098, 95% CI = 1.006 to 1.200, P = .037). Local myalgia was negatively associated with HAattrTMD (OR = .295, 95% CI = 0.098 to 0.887, P = .030). CONCLUSIONS: Painful TMD patients who report headache in the temple area and are diagnosed as having local myalgia rather than myofascial pain with referral probably do not have HAattrTMD. The diagnosis of HAattrTMD may point to a central sensitization process and possible current/future chronic TMD conditions.

Restricted Mouth Opening in Head and Neck Cancer: Etiology, Prevention, and Treatment.

Restricted mouth opening or trismus is often encountered in patients with head and neck cancer. The restriction may be the presenting sign of malignancy, a sequela of tumor site or growth, an adverse effect of oncologic treatment, or a first sign of tumoral recurrence. In general, any insult to the temporomandibular joint, masticatory muscles, or their neural innervation may cause limitation in mouth opening. The etiologies leading to trismus are as follows: myospasm secondary to tumor infiltration; reflectory myospasm; radiation-induced myositis and myofibrosis; temporomandibular joint involvement with tumor; unfavorable postsurgical scarring; muscle and joint atrophy secondary to immobilization; pain; jaw fracture and hardware failure; and infection. Preventive measures should be implemented before, during, and after treatment. These measures include identification of high-risk patients, utilization of dose-sculpting radiation techniques whenever possible, performing reconstruction at the same time of resective surgery whenever feasible, and initiating mobilization exercises as early as possible. When trismus develops, treatments are often challenging and disappointing. These include physical therapy, mouth opening appliances, drug therapy, and release surgery. All medical specialties dealing with head and neck cancer should be familiar with the diagnosis and prevention of trismus and make an effort to ensure patients are referred to the appropriate care when needed. Trismus should not be considered a trivial sequela of head and neck cancer.

Ultrasound-Guided Botulinum Toxin Injections into the Salivary Glands for the Treatment of Drooling.

BACKGROUND: Drooling is the unintentional loss of saliva from the mouth, usually caused by poor coordination of the swallowing mechanism. It is commonly seen in patients with chronic neurologic disorders, such as Parkinson's disease, amyotrophic lateral sclerosis (ALS), cerebral palsy, and stroke, as well as in patients with cognitive impairment and dementia. OBJECTIVES: To evaluate the efficacy and safety of ultrasound-guided botulinum toxin injections into the parotid and submandibular salivary glands for the treatment of drooling. METHODS: We conducted a retrospective analysis of the medical records of 12 consecutive patients treated with botulinum toxin injections into the parotid and submandibular glands for the first time. The primary outcome variable was the subjective improvement of drooling on a 5-point scale. Secondary outcome variables were duration of the therapeutic effect, request to undergo additional treatment, and adverse events. RESULTS: Of 12 patients, 8 (67%) reported considerable improvement after treatment, 3 reported slight improvement, and 1 reported development of dry mouth. All patients stated that they felt the effects 1 week after the injections; the mean duration of the therapeutic effect was 4.5 months (range 3-9 months). One patient suffered from local hematoma and ecchymosis that did not require medical care. Another patient complained of difficulty swallowing, which did not require medical treatment and resolved spontaneously within 1 month. CONCLUSIONS: Ultrasound-guided botulinum toxin injections into the parotid and submandibular glands seem to be a safe and effective therapy for the treatment of drooling. Further long-term prospective studies with varying doses are warranted.

Three-Dimensional Orofacial Changes Occurring After Proportional Condylectomy in Patients With Condylar Hyperplasia Type 1B (Unilateral Hemimandibular Elongation).

PURPOSE: To evaluate 3-dimensional orofacial changes that occurred after proportional condylectomy that was not followed by orthognathic surgery in patients with condylar hyperplasia type 1B (unilateral hemimandibular elongation). MATERIALS AND METHODS: This retrospective analysis used the medical records of 14 skeletally mature patients. Transverse, vertical, and horizontal cephalometric analyses of photographs and radiographs were undertaken. A comparison of preoperative and postoperative measurements was conducted. RESULTS: After proportional condylectomy, transverse chin position and vertical lip cant improved to various degrees, whereas ramus and condyle height and mandibular lower border discrepancy worsened to different extents. The prominence of the gonial angle of the affected (operated) side increased in all patients after surgery, and this contributed to better symmetry only when the preoperative prominence was small (flat), whereas the opposite occurred when the preoperative prominence was large (bulky). After condylectomy, there was posterior displacement of the pogonion point (setback), which was favorable in cases with a preoperative concave profile and unfavorable in cases with a preoperative convex profile. CONCLUSION: Proportional condylectomy can successfully arrest the hyperplastic growth of the affected condyle; however, it rarely achieves perfect symmetry of the face. Although it improves some facial features, other facial traits are worsened. Surgeons should have a full understanding of the 3-dimensional changes occurring after proportional condylectomy and should be able to predict, based on preoperative findings, the anticipated improvement or worsening of different facial features.

Role of oral examination in newly diagnosed multiple myeloma patients: A safe and simple way to detect light chain amyloidosis.

OBJECTIVE: Up to 30% of multiple myeloma (MM) patients have subclinical amyloid deposits. These patients are under-recognized and are more susceptible to drug toxicity, bleeding and death. Early diagnosis and adjustment of treatment are crucial. Biopsies of oral mucosa might be a potentially useful diagnostic tool. The objective of this study was to assess the prevalence and characteristics at presentation of oral amyloidosis in a large cohort of MM patients. METHODS: The prevalence and characteristics of oral amyloidosis in a large cohort of MM patients who were referred for oral evaluation before and during bisphosphonate therapy were assessed, retrospectively. RESULTS: Among 212 patients analysed, 13 (6%) were diagnosed with concomitant light chain (AL) amyloidosis. In 54% (n = 7), lesions in the oral cavity compatible with amyloid deposition were detected by examination. CONCLUSIONS: The salient feature of this study is the high prevalence of oral manifestations among MM patients with amyloidosis. These results highlight the value of routine oral cavity examination and biopsy as a safe and simple method for detecting light chain amyloidosis.

Arthroscopy of the Temporomandibular Joint for the Treatment of Chronic Closed Lock.

BACKGROUND: Temporomandibular joint (TMJ) disorders affect roughly 5% of the population. Chronic closed lock is one of the more common temporomandibular disorders and is characterized by limited mouth opening and various degrees of joint pain and dysfunction. OBJECTIVES: To evaluate the efficacy and safety of arthroscopic lysis and lavage of the TMJ to treat limited mouth opening in patients suffering from chronic closed lock. METHODS: This is a retrospective analysis of the medical records of 47 patients with chronic closed lock treated with arthroscopic lysis and lavage. Patients were diagnosed preoperatively with closed lock of the TMJ and were unresponsive to previous conservative therapy. Three outcome variables were used to assess the efficacy of treatment: maximal mouth opening, subjective evaluation of overall improvement by the patient (on a 3 grade scale: "excellent," "fair," and "poor"), and length of hospital stay. In addition, complications were reported. RESULTS: The maximal mouth opening values increased from a mean of 27 ± 4.7 mm preoperatively to a mean of 38 mm ± 5.4 mm postoperatively. The subjective evaluation of overall improvement was "excellent" in 15 patients (32%), "fair" in 21 (45%), and "poor" in 11 (23%). Success was defined as a maximal mouth opening of 35 mm or more after arthroscopy, and not reporting a "poor" result in the subjective evaluation. This was achieved in 36 patients, yielding a success rate of 77%. The mean length of hospital stay was less than one day (0.78 days). The complication rate was low (8%) and all complications resolved within 2 weeks. CONCLUSIONS: Arthroscopic lysis and lavage is a simple, safe, and efficient minimally invasive intervention for the treatment of chronic closed lock of the TMJ.

Treatment of Intermittent Locking of the Jaw in Wilkes Stage II Derangement by Arthroscopic Lysis and Lavage.

PURPOSE: This study evaluated the efficacy of a standardized arthroscopic lysis and lavage in decreasing the intermittent locking and transient pain episodes that characterize patients with early- to intermediate-stage internal derangement (Wilkes stage II). PATIENTS AND METHODS: This is a retrospective analysis of the medical records of 27 patients (39 joints) treated by arthroscopic lysis and lavage in the authors' department during a 2.5-year period. Patients were diagnosed preoperatively as having mild internal derangement (Wilkes stage II) that was unresponsive to previous conservative therapy. Three outcome variables were used to assess the efficacy of treatment: 1) frequency of intermittent locking or catching episodes, 2) severity of pain, and 3) maximal interincisal opening. RESULTS: Ninety-two percent of patients reported improvement regarding the locking and catching episodes. Most patients (77%) denied experiencing any locking episodes during the follow-up period, and 15% reported experiencing locking episodes but with less frequency or severity. The median duration of symptoms for patients who were freed from locking episodes was 16 months compared with 36 months for patients who still had locking episodes after treatment (P = .059). Mean pain values (visual analog scale, 0 to 10) decreased from 7.5 preoperatively to 3.2 postoperatively (P < .0001). For maximal interincisal opening, there was no significant difference after treatment (mean, 39.4 mm preoperatively vs 41.3 mm postoperatively; P = .06). Success was defined as a decrease in locking episodes, a decrease of pain, and maintenance of normal interincisal opening (>36 mm). The overall success rate was 81.4% (22 of 27 patients). CONCLUSION: Arthroscopic lysis and lavage is an efficient treatment modality for treating mild internal derangement of the temporomandibular joint. It decreases the frequency of locking episodes and decreases transient pain periods.

Arthroscopic lysis and lavage for internal derangement of the temporomandibular joint.

INTRODUCTION: Arthroscopy of the temporomandibular joint (TMJ) is a valuable diagnostic and therapeutic tool for various intra-articular disorders, especially internal derangement (ID) of the TMJ. OBJECTIVES: To evaluate the efficacy and safety of a standardized arthroscopic procedure for the treatment of two stages of ID; early/intermediate stage and intermediate/late stage. MATERIALS AND METHODS: Retrospective analysis of medical records of 78 patients (99 joints) treated by arthroscopic lysis and lavage in the authors' department during a 5-year period. Patients were diagnosed preoperatively as suffering from ID of the TMJ. The results were stratified according to the stage of ID. Three outcome variables were used to assess efficacy of treatment: Maximal interincisal opening (MIO), level of pain on a visual analog scale (VAS), and frequency of intermittent locking episodes. In addition, complications were reported. RESULTS: Mean MIO of the group of patients with intermediate/late stage ID increased from 27 ± 4.7 mm preoperatively to 38 ± 5.4 mm postoperatively (P < 0.0001). For the group of patients with early/intermediate stage ID, mean MIO did not change significantly after arthroscopy (39.1 ± 6.2 mm compared to 41.4 ± 5 mm, P = 0.06), however, subjective evaluation of pain on a VAS decreased from 7.2 ± 1.2 preoperatively to 3.4 ± 2.2 postoperatively (P < 0.0001), and 80% of the patients (25 of 31) denied experiencing intermittent locking episodes after treatment (P < 0.0001). CONCLUSION: Arthroscopic lysis and lavage is a safe and effective therapeutic modality for the treatment of both mild and advanced stages of ID.