Hand-Carried Ultrasonography Instrumentation in the Diagnosis of Temporomandibular Joint Dysfunction.

Internal derangement (ID) in the temporomandibular joint (TMJ) is defined as a mechanical problem of the joint that interferes with its function. It is attributed to an abnormal interaction among the articular disc, condyle, and joint eminence. The aim of this study is to evaluate diagnostic efficacy of non-invasive hand-carried ultrasonography instrumentation (US) to provide high-level images for a correct diagnosis of ID. Twenty-eight ID patients, 15 female and 13 males, were examined both clinically and by MRI images in order to achieve a diagnosis of ID (using Helkimo index). Then, they were submitted to US examination with a 12 MHz transducer by using hand-carried instrumentation by a clinician that was blind to their diagnosis and clinical data. TMJ US examination was performed with the mouth closed and mouth open, with proper technique. Each position was then evaluated with two different orientations of the transducer. US showed acceptable results in identifying bone structures. Lower values of diagnostic efficacy were obtained for disc position during joint movements with respect to MRI images. MRI still represents the gold standard for the identification of joint structures. If not corroborated by clinical and anamnestic data, the diagnostic efficacy of US in identifying the position of the disc during opening and closing jaw movements appears limited than compared to MRI.

Ultra-low-frequency transcutaneous electric nerve stimulation (ULF-TENS) in subjects with craniofacial pain: A retrospective study.

Objective: The aim of the present study was to evaluate the effects of ultra-low-frequency transcutaneous electrical nerve stimulation (ULF-TENS) on pain and electromyographic values in subjects affected by temporomandibular disorders. Methods: A retrospective evaluation of 80 non-consecutive patients (58 women, 22 men, mean age 35.3 ± 9.9 years) suffering from pain associated with temporomandibular disorders was performed. The sample was treated with ULF-TENS, and outcomes were evaluated by anamnestic index, dysfunction index, visual analog scale, and surface electromyography of the masticatory muscles. Results: An improvement was seen in pain and electromyographic values. The visual analog scale showed a mean decrease from 8 to 2; surface electromyographic values in the masseter area decreased from 2.7 ± 0.1 to 1.5 ± 0.1. Conclusion: ULF-TENS seems to be effective in reducing pain symptomatology of subjects affected by temporomandibular disorders, with a reduction in the surface electromyographic activity in the masseter area.

Different Solutions for Damaged Nasotracheal Tube during Maxillofacial Surgery: A Case Series.

Difficult airway management and intraoperative tube damage are important problems during maxillofacial surgery. Damage occurs frequently during the surgery, and the anesthesiologist must be ready to find a quick and safe solution. Replacing the damaged endotracheal tube involves additional difficulties, and various factors must be evaluated. We present two cases of nasotracheal tube (NTT) damage suffered during maxillofacial surgery. The different intraoperative conditions led us to decide for the replacement of NTT in one case and for conservative action in the other. The purpose of this article is to highlight the difficulties that the anesthesiologist may have in deciding quickly what is the best approach in case the endotracheal tube is damaged during maxillofacial surgery and possibly try to provide a rapid and safe solution for the situation.

Cervical injury related to mandibular fractures. A retrospective study of 315 cases.

Objective To define the association between mandibular fractures and alterations of the cranio-atlo-axial joint (CAAJ). Methods 315 cases of displaced mandibular fractures were retrospectively evaluated by CT scan and cervical X-ray for associated alterations of the CAAJ. Statistical analysis employed the chi-square and Cohen's kappa coefficient. Results Single fractures amounted to 69.84% and multiple fractures to 30.16% of total fractures. CT scans showed a rotation of the atlas on the same side of single fractures and subluxation of the CAAJ. Vertical derangement of the joint was observed in 79.65% of single fractures and in 20.35% of multiple fractures. Approximately16.19% of all displaced mandibular fractures showed cervical disorders at long-term follow-up. Discussion The outcomes of this study revealed an association between traumatic mandibular fractures and CAAJ, accompanied by clinical disorders. These conditions require clinical attention due to their effects on long-term craniocervical functionality and future forensic issues.

Bilateral Central Giant Cell Granuloma of the mandibular angle in three females from the same family.

In literature there are few reports about multiple CGCG. But this is the first report of bilateral CGCG of the mandibular angles in three females from the same family.This report describes three cases of females from the same family - a mother and two young daughters - with bilateral CGCG in their jaw angles. All the lesions were surgically removed and the histopathologic diagnosis was always identical: giant cell central granulomas, with patterns that were absolutely superimposable between them and with that of the mother.The hypothesis is that this presentation of CGCG may be defined as hereditary bilateral CGCG of the mandibular angles (or also, cherubism-like lesions).

p53 as a prognostic marker associated with the risk of mortality for oral squamous cell carcinoma.

Oral squamous cell carcinoma (OSCC) is often associated with a poor prognosis. The purpose of the present study was to investigate survival and the risk of mortality in OSCC with regard to stage, tumor site and p53 expression. A retrospective study was performed on 150 non-consecutive cases of OSCC that were observed between January 1992 and January 2012, and were selected from a total of 580 patients according to the criteria of the homogeneity of histopathological grading (G2). The medical records were reviewed for 48 cases with disease at stage I [37 males, age 64.7±5.7 years (mean age±standard deviation); 11 females, age 70.0±3.37 years]; 27 cases with stage II (15 males, age 64.5±5.6 years; 12 females, age 69.2±3.9 years); 58 cases with stage IVa (42 males, age 66.9±5.3 years; 16 females, age 64.2±6.5 years); and 17 cases with stage IVb (16 males, age 65.7±5.4 years; 1 female, age 69 years). Monoclonal p53 antibody (clone DO-7) was used to perform the p53 immunohistochemical study. A significant association was found between the site of the tumor and p53 overexpression (P<0.0001). Stage I-II cases showed a higher cumulative probability of a 24-month survival time than stage IVa-IVb cases (P<0.0001). Cheek, floor and soft palate tumors showed a worse prognosis (P<0.0001) and tumors with p53 overexpression >50% showed a poor survival rate (P<0.0001) compared with tumors of the attached gingiva, tongue and retromolar trigone. The findings allowed the quantification of the risk mortality from OSSC with regard to stage, tumor site and the p53 expression pattern of the tumor. Data supported the absolute indications for wide surgical margins (radical surgery) in cases of T1-T2 N0 tumors of the tongue, floor, retromolar trigone and attached gingiva when p53 overexpression is >50% in association with a higher risk of mortality compared with when p53 overexpression is <50%.

Association between p53 status, human papillomavirus infection, and overall survival in advanced oral cancer after resection and combination systemic treatment.

Our previous study on 75 cases of advanced oral squamous cell carcinomas (SCC) treated by neoadjuvant chemotherapy, radical surgery, and radiotherapy showed that overexpression of p53 of more than 50% indicated a strong probability of genetic mutation, and tumours that are characterised by this p53 pattern respond poorly to treatment and have a poor prognosis (p= 0.0001). We have studied the same cohort of patients retrospectively to investigate the incidence of human papillomavirus-16 (HPV16) infection, the relation to the overexpression or mutation of the p53 gene, and the association with overall survival. There were 57 men and 18 women, mean age 67 (range 57-72) years. HPV16 infectivity was found in 66 patients (88%) - 49/57 men (86%) and 17/18 women (94%). There was no significant difference between the sexes (p=0.32). The cumulative survival of the entire group after a follow-up of 38 months was 26% (SE 6.4). The log rank test indicated that the combination of HPV-16 infectivity and p53mutation was significantly related to prognosis (p=0.000). On the other hand HPV16 infectivity alone was not significantly related to prognosis (p=0.78) The incidence of HPV-16 infection decreased with increasing immune p53 expression (p=0.005), whereas that of the HPV16+p53mutation combination increased with increasing immune p53 expression (p=0.000). The results show the importance of the investigation of HPV and p53 expression to define prognosis in oral SCC.

Epidemiology, pharmacology and clinical characterization of bisphosphonate-related osteonecrosis of the jaw. A retrospective study of 70 cases.

BACKGROUND AND OBJECTIVES: Bisphosphonates are widely prescribed drugs whose principal capacity is inhibiting the osteoclast function. In 2003 a complication related to their administration, bisphosphonate-related osteonecrosis of the jaw (BRONJ), was described. The objectives of this study were to identify diagnosed cases of BRONJ in a third-level hospital over 8 years, evaluating the main features in relation to the disease, the bisphosphonate and the presence of local or general risk factors that could trigger the BRONJ. METHODS: Patients diagnosed with BRONJ in a centre of reference for a population of 1,100,000 inhabitants were selected. Variables analysed were classified into 3 groups: patients, bisphosphonate (focusing on dose and weighting dose/potency) and osteonecrosis. RESULTS: Seventy cases were studied -44 women and 26 men-, with a mean age of 66.8 years. Eighteen patients received bisphosphonates orally and 52, intravenously. The mean time of administration was 26.53 months. In 67.1% of the patients it was possible to identify a local trigger, with the most common being tooth extraction (48.6%). Bone exposure was present in 89.2% of the cases, while 12 patients developed BRONJ without exposed bone, with only pain and/or chronic sinus tracts. Complete resolution was achieved in 58.6% of the patients, with a mean time of control of 16.28 months. CONCLUSIONS: 25% of the BRONJ cases were related to the administration of oral bisphosphonates, especially alendronate. Zoledronic acid was the bisphosphonate that required the fewest milligrams to induce osteonecrosis. Single bone exposure was the most common clinical finding, especially in the molar mandibular region in patients with metastatic disease.

Oral lymphomatoid granulomatosis, the first sign of a 'rare disease': a case report.

INTRODUCTION: Lymphomatoid granulomatosis is an uncommon Epstein-Barr virus-positive B-cell lymphoma, an angiocentric-destructive process with a predominant T-cell background. Lymphomatoid granulomatosis is listed among rare diseases. Common localization is in the lungs. Lymphomatoid granulomatosis with oral involvement is described in only two reports. In this report, we describe a third case of oral lymphomatoid granulomatosis. CASE PRESENTATION: A 65-year-old Caucasian man with a gingival ulceration underwent a biopsy. The histological pattern was compatible with a grade III lymphomatoid granulomatosis. The staging revealed a nodular lesion in the lower lobe of his right lung. Our patient also presented with hemoptysis, an unusual and not reported clinical sign. Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone chemotherapy was performed every three weeks for six cycles. CONCLUSIONS: The pulmonary nodule and the gingival lesion disappeared. At eight-month follow-up, our patient is disease-free. We wish to emphasize that the oral manifestation described was the first sign of the disease and allowed for diagnosis. This case report adds to the medical literature for the particular clinical presentation of this rare disease.

Evaluation of p53 protein as a prognostic factor for oral cancer surgery.

We have analysed concentrations of the p53 protein in advanced oral carcinomas immunohistochemically and genetically to detect the percentage of overexpression of this antioncogene that indicates a high probability of mutation. This would point to it being a useful prognostic factor, if we consider the importance of the relation between genetic alterations of p53 and poor overall survival. Seventy-five non-consecutive patients with oral squamous cell carcinoma and metastatic nodes were enrolled if there was homogeneity in histopathological grading (G2) of their tumours, and they were treated according to a multidisciplinary treatment plan. Monoclonal antibodies, extraction of DNA, and amplification of the polymerase chain reaction (PCR) were used for the immunohistochemical and genetic analyses. There was a significant inverse correlation between p53 overexpression and response to chemotherapy and a stronger association between high P53 overexpression (%) and a genetic mutation of p53 (p=0.0001). More than 50% overexpression indicated a strong probability of genetic mutation. There was no association between response to chemotherapy and age-groups or TNM classification (p=0.2), but there was a significant one between sex and site of tumour (p<0.001). Three prognostic factors were significantly related to prognosis: site of tumour (p=0.01), response to chemotherapy (p=0.002), and immuno p53 (p=0.0001). A tumour that is characterised by p53 overexpression of more than 50% indicates a poor prognosis.

Pathological (late) fractures of the mandibular angle after lower third molar removal: a case series.

INTRODUCTION: Pathological (late) fracture of the mandibular angle after third molar surgery is very rare (0.005% of third molar removals). There are 94 cases reported in the literature; cases associated with osseous pathologies such as osteomyelitis or any local and systemic diseases that may compromise mandibular bone strength have not been included. We describe three new cases of pathological (late) fracture of the mandibular angle after third molar surgery. CASE PRESENTATIONS: The first patient was a 27-year-old Caucasian man who had undergone surgical removal of a 3.8, mesioangular variety, class II-C third molar 20 days before admission to our clinic. The fracture of his left mandibular angle, complete and composed, occurred during chewing. The second patient was a 32-year-old Caucasian man. He had undergone surgical removal of a 3.8, mesioangular variety, class II-B third molar 22 days before his admission. The fracture, which occurred during mastication, was studied by computed tomography that showed reparative tissue in the fracture site. The third patient was a 36-year-old Caucasian man who had undergone surgical removal of a 3.8, vertical variety, class II-C third molar 25 days before the observation. In this case the fracture of his mandibular angle was oblique (unfavorable), complete and composed. The fracture had occurred during chewing. We studied the fracture by optical projection tomography and computed tomography.All of the surgical removals of the 3.8 third molars, performed by the patients' dentists who had more than 10 years of experience, were difficult. We treated the fractures with open surgical reduction, internal fixation by titanium miniplates and intermaxillary elastic fixation removed after 6 weeks. CONCLUSIONS: The literature indicates that the risk of pathological (late) fracture of the mandibular angle after third molar surgery for total inclusions (class II-III, type C) is twice that of partial inclusions due to the necessity of ostectomies more generous than those for partial inclusions. Other important factors are the anatomy of the teeth and the features of the teeth roots. These fractures predominantly occur in patients who are older than 25 years. The highest incidence (67.8% of cases) is found in the second and third week postsurgery. We emphasize that before the third molar surgery it is extremely important to always provide adequate instructions to the patient in order to avoid early masticatory loads and prevent this rare event.

Inflammatory myofibroblastic tumor of the lung and the maxillary region: a benign lesion with aggressive behavior.

Inflammatory myofibroblastic tumor (IMT) is a rare mass-forming lesion characterized by fibroblastic or myofibroblastic spindle cell proliferation with varying degrees of inflammatory cell infiltration. Although it has been reported in virtually every organ in the body, the lung is the most common site of involvement. Extrapulmonary IMTs, although rare, have been reported and are characterized by different, more aggressive behavior. We report an extremely rare case of maxillary metastases of pulmonary IMT. Lung IMT was initially misdiagnosed, and oral lesion mimicked clinically and radiologically a radicular cyst. On histologic examination, cells exhibited diffuse and intense immunoreactivity for α -smooth muscle actin and vimentin whereas both pulmonary and oral IMTs presented absence of cellular atypia and lack of expressivity of oncogenic determinants. Distant metastases of lung IMT are extremely unusual, and this is the first report to our knowledge with this particular clinical course. Despite the possibility that the present case could also represent a metachronous multifocal IMT, with pulmonary and extrapulmonary lesions, similar histopathological and immunohistochemical patterns in lung and maxillary region suggest a metastatic course.

Image-guided transoral biopsy in a boy with Grisel's syndrome.

Grisel's syndrome is a disease characterized by an atlanto-axial rotatory subluxation following acute inflammation of the upper respiratory tract. The syndrome has a good prognosis as it usually heals with antibiotics, despite the delayed serious complications that have been reported. When neuroradiological investigation does not allow an accurate differential diagnosis between a tumor and osteomyelitis, an image-guided transoral biopsy is a safe, fast, minimally invasive, as well as effective, procedure.

DNA aneuploidy as a topographic malignant transformation pattern in a pleomorphic adenoma of long-term evolution: a case report.

INTRODUCTION: We present a case of long-term evolution of a submandibular pleomorphic adenoma. There is little information about topographic malignant transformation patterns of pleomorphic adenomas. CASE PRESENTATION: We extensively analyze a giant submandibular mixed tumor of 25-year evolution in a 57-year-old Caucasian woman. Deoxyribonucleic acid ploidy was evaluated in different superficial and deep areas using flow cytometry analysis and correlated with pathological and immunohistochemical characteristics. Superficial areas exhibited a typical histological pleomorphic adenoma pattern and were deoxyribonucleic acid diploid. Deep samples showed deoxyribonucleic acid aneuploidy, atypical histological benign features and expression of markers involved at an early-stage of malignant transformation, such as tumor protein 53 and antigen Ki67. CONCLUSION: These findings revealed that deep tumor compartments may be involved in the initial stages of malignant transformation. Deoxyribonucleic acid ploidy analysis may provide an additional diagnosis tool and indicate 'uncertain' areas that require careful study to avoid diagnostic errors. Larger studies are needed to confirm our results and to evaluate the usefulness of the technique.

High-grade chondroblastic and fibroblastic osteosarcoma of the upper jaw.

Osteosarcomas (OS) are extremely uncommon in maxillofacial region (6%-10% of all sarcomas). Jaw lesions are diagnosed on average two decades later than sarcomas of long bone, with a peak incidence between 20 and 40 years. Head and neck OS (HNOS) are associated with a lower metastatic rate than long bone OS, and they have a better 5-year survival rate, ranging between 27% and 84%. Approximately 80% of HNOS originate from soft tissues, while 20% arise from bone. The majority of OS were classified as osteoblastic HNOS (77.0%), followed by chondroblastic (15.8%) and fibroblastic (3.4%). Patients older than 60 years were more likely to be diagnosed with other histologic types compared with patients 60 years or younger. The authors describe a rare case of Stage II high-grade mixed chondroblastic and fibroblastic osteosarcoma of the upper jaw diagnosed in a subject older than 60 years. CT i.e., total body scintigraphy, radiograph of chest, and epathic ultrasonography have been executed to staging (T3N0M0). The size of the tumor >6 cm, histopathological findings, and patient older than 60 years, made necessary a multimodality therapy. Surgery (right subtotal maxillectomy with closure of surgical area by local sliding and advanced cheek flap) and adjuvant radiotherapy (for overall 6500 Gy) were the definitive treatment. Follow-up at 2 years shows no local recurrence and the patient is disease free.