Arthroscopic Disc Suturing and Repositioning Technique for Treating Anteriorly Displaced Disc in Temporomandibular Joint Disorders: A Posterior Anchorage Technique.

Several treatment modalities have been reported for patients with arthrogenous temporomandibular disorders. The most common temporomandibular disorder is internal derangement, usually accompanied by displacement of the articular disc. Most often anteriorly and medially displaced, patients may develop clicking, impaired jaw function, and pain. Articular disc repositioning has been described as an effective method to eliminate interference during mandibular translation, improving mandibular range of motion, and eliminating pain. In this article, we present a new, simple, and reproducible technique without requiring specific instruments for repositioning and suturing the articular disc with posterior anchorage fixed to the tragus cartilage. It has the advantages of a better anteroposterior vector of traction force, without adverse effects as lateralization of the articular disc and skin depression, commonly presented in other techniques.

Mechanical characteristics of the maxillary sinus Schneiderian membrane ex vivo.

OBJECTIVES: It has been speculated that certain Schneiderian membrane thickness (SMT) might be more prone to perforation. This investigation was aimed at studying the mechanical characteristics of the Schneiderian membrane under one- and two-dimensional tests and their correlation to the histological SMT in human samples. MATERIAL AND METHODS: Sixteen Schneiderian membranes were collected from 11 cadaver heads treated with Thiel's embalming method. The samples were processed and analyzed clinically and histologically. One-dimensional maximum elongation until perforation and two-dimensional resistance to ball penetration were performed after the biopsy. Data was analyzed by using the Wilcoxon rank test and the Spearman's rank correlation. RESULTS: The histological SMT was 1.36 ± 0.42 mm, whereas the clinical thickness was 0.27 ± 0.21 mm, yielding statistical significance (p = 0.000). The resistance under ball penetration was 0.59 ± 0.43 N and the mean maximum elongation in the one-dimension test 11.19 ± 7.14 mm. Expressed in percentage, the mean stretch was 241.36 ± 227.97% (range 31.5 up to 947%). A weak positive correlation was found between the ball penetration test and the SMT (r = 0.10, p = 0.711), while a weak negative correlation was found between stretching test and the SMT (r = -0.021, p = 0.94). CONCLUSIONS: Mechanical tests seem to indicate that SMT might not significantly predispose to Schneiderian membrane perforation. Hence, other anatomical and operator's factors should be considered of surpassing importance. CLINICAL RELEVANCE: Thinner SM might be more prone to perforation when detaching it from the maxillary sinus antrum; however, a thick membrane is not prevented to tear, as their resistance under elastic forces is not higher than thinner ones.

Consensus Report and Recommendations on the Management of Late-stage Internal Derangement of the Temporomandibular Joint.

Introduction: This report investigates late-stage internal derangement (ID) of the temporomandibular joint (TMJ) with the aim of establishing a more effective and personalized treatment protocol to improve patients' quality of life (QoL). Material and methods: A consensus was reached among maxillofacial surgeons specializing in LSID, based on a literature research and collective expert experience following the Delphi method. Consensus was considered to be achieved when a response received at least 80% of votes. Results: Four expert groups were established, respectively, focusing on diagnosis, minimally invasive surgery (MIS), open surgery and joint replacement. A comprehensive approach to late-stage ID of the TMJ requires a consensus report. This underscores the need for a personalized treatment plan, considering the variability in clinical presentations and progression of this pathology. Our recommendations aim to optimize clinical outcomes and enhance patient QoL.

Temporomandibular joint arthrocentesis. Review of the literature.

The treatment of the temporomandibular joint (TMJ) is still controversial. TMJ arthrocentesis represents a form of minimally invasive surgical treatment in patients suffering from internal derangement of the TMJ, especially closed lock. It consists of washing the joint with the possibility of depositing a drug or other therapeutic substance. Resolution of symptoms is due to the removal of chemical inflammatory mediators and changes in intra-articular pressure. Numerous clinical studies regarding this technique have been published. The goal of this paper is to review all clinical articles that have been published with regard to the critique of this technique. 19 articles with different designs fulfilling selection guidelines were chosen. A series of clinical and procedure variables were analyzed. Although the mean of improvement was higher that 80%, further research is needed to determine more homogeneous indications for TMJ athrocentesis.

Long-Term Dislocation of the Mandible: Is there an Algorithm to Success? Intraoperative Decision and Review of Literature.

PURPOSE: Long-term TMJ dislocation is a rare condition. It occurs when an acute luxation remains untreated in time. METHODS: A 52-year-old man presented with a long-term TMJ luxation in the context of Steinert's disease. A discectomy together with condylectomy and eminectomy was performed, obtaining an adequate reduction of the luxated condyle and disc. RESULTS: Twelve months after the operation, the condition has not recurred at all. A stable and centred occlusion was checked; his MIO was over 30 mm. CONCLUSION: The combination of these three techniques could be a good option in cases of Steinert's myotonia, where the condyle luxation becomes chronic and irreducible due to the altered neuromuscular condition. There is still no consensus regarding the treatment for long-term TMJ dislocations. New and more solid studies may be needed in order to find adequate treatment protocols for this condition.

Costochondral graft with green-stick fracture used in reconstruction of the mandibular condyle: experience in 13 clinical cases.

Since its publication in 1920 by Gillies, costochondral grafts have been used by surgeons to replace and injured mandibular condyle and to reconstruct the temporomandibular joint. This procedure is currently applied in cases of congenital dysplasia, developmental defects, temporomandibular ankylosis, neoplastic disease, osteoarthritis and post-traumatic dysfunction. Over the years, various procedures for the reconstruction with this type of graft have been described. In 1989, Mosby and Hiatt described a technique for setting the graft securely, reducing the space between the graft and the mandibular area. In 1998, Monje and Martín-Granizo developed a variation of this method, enabling a precise adaptation of the costochondral graft to the remaining mandibular ramus. The aim of this study is to evaluate the functional and anatomic results of the costochondral graft treatment by green-stick fracture for reconstruction of the TMJ in the 10 years following the description of this technique. We carry out a retrospective study of thirteen cases of temporomandibular pathology (tumors, ankylosis and hypoplasia) treated during a period of ten years from 1998 to 2008. In all these cases, the technique described by Monje and Martín-Granizo was used: removal of the sixth rib, fixation to a titanium mini-plate using screws, making an internal corticotomy in order to obtain a green-stick fracture of the outer cortex, providing adequate adaptation of the graft to the mandibular ramus. The graft was then set in place, attaching it with titanium screws. This technique was successful in achieving optimal ossification, a good interincisal opening and satisfactory cosmetic results. In conclusion, according to our experience, the green-stick fracture for the adaptation of costochondral grafts to the remaining mandibular ramus has presented outstanding results in the surgical treatment of temporomandibular pathology.

Metastasis of renal clear-cell carcinoma to the oral mucosa, an atypical location.

The majority of cases of metastatic tumors involve the mandible and some the maxilla but they are considerably less common in intraoral soft tissues. In addition, the primary tumor is known in the majority of cases; although in one-third of such cases, metastasis is the first clinical manifestation. The most common primary tumors metastasizing to the mouth are lung carcinoma in men and breast carcinoma in women. An oral metastasis implies a serious prognosis, as in the majority of patients there is multiple organ involvement at the time of diagnosis. We present the case of a 52-year old patient with renal pathology who came to the emergency room due to a rapidly increasing gingival tumor. With the provisional clinical diagnosis of a pyogenic granuloma,the tumor was excised. Subsequent anatomopathological analysis revealed a tumor metastasis compatible with clear-cell carcinoma, and its renal origin was confirmed by means of immunohistochemical techniques.

Preclinical randomized controlled trial of bilateral discectomy versus bilateral discopexy in Black Merino sheep temporomandibular joint: TEMPOJIMS - Phase 1- histologic, imaging and body weight results.

INTRODUCTION: The role of temporomandibular joint (TMJ) surgery is not well defined due to a lack of quality randomized controlled clinical trials, comparing different TMJ surgical treatments with medical and placebo interventions. The temporomandibular joint interposal study (TEMPOJIMS) is a rigorous preclinical trial divided in 2 phases. In phase 1 the authors investigated the role of the TMJ disc and in phase 2 the authors evaluated 3 different interposal materials. The present work of TEMPOJIMS - phase 1, aims to evaluate histopathologic and imaging changes of bilateral discectomy and discopexy in Black Merino sheep TMJ, using a high-quality trial following the ARRIVE guidelines. MATERIAL AND METHODS: This randomized, blinded and controlled preclinical trial was conducted in 9 Black Merino sheep to investigate histopathologic (primary outcome), imaging and body weight (secondary outcomes) changes after bilateral discectomy, discopexy and sham surgery. RESULTS: Significant changes were noticed in discectomy group, both in imaging and histopathologic analyses. Body weight changes were most pronounced in the discectomy group in the first 4 months after surgery with recovery to baseline weight 6 months after surgery. Discopexy induced nonsignificant changes in histopathologic, imaging and body weight analyses. CONCLUSIONS: This study reinforces the importance of developing an effective interposal material to substitute the TMJ disc and the need to explore the molecular mechanisms that underlie TMJ cartilage degeneration. The study design proposed in TEMPOJIMS represents an important progress towards future rigorous TMJ investigations.

Is fine-needle aspiration a reliable tool in the diagnosis of malignant salivary gland tumors?

PURPOSE: The purpose of the present study was to establish the reliability of fine needle aspiration (FNA) in the diagnosis of malignant salivary gland tumors in our population and to compare our results with those of other authors. MATERIAL AND METHODS: This was a retrospective study of clinical data from 172 patients, 153 parotid tumors and 19 submandibular tumors who underwent preoperative FNA between January 2004 and December 2013. Sensitivity, specificity, positive and negative predictive values of FNA for the preoperative diagnosis of malignancy were analyzed. RESULTS: For the diagnosis of malignancy an S value of 60% was obtained, which means that 40% of malignant tumors were not diagnosed by FNA. Besides an E value of 97.5% was obtained, thus indicating that FNA was negative for malignancy in up to 97.5% of all benign neoplasms. According to predictive values, we observe that FNA hit in 83.3% cases given as malignant and in 92% of cases giving as benign (PPV=83,3%; NPV=92%). CONCLUSION: With a scarce 60% sensitivity value in our series, fine needle aspiration has evident limitations for diagnosis of malignancy in major salivary gland neoplasms. Being highly conditioned by the staff and the conditions in which it is performed, FNA is a complementary test that helps the preoperative diagnosis of the major salivary glands with radiological tests, medical history and physical examination, but that alone it is not defining of malignancy.

Cellular, Vascular, and Histomorphometric Outcomes of Solvent-Dehydrated vs Freeze-Dried Allogeneic Graft for Maxillary Sinus Augmentation: A Randomized Case Series.

PURPOSE: The aim of this study was to compare solvent dehydrated human allograft (SDHA; Puros Allograft) and freeze-dried human allograft (FDHA; MinerOss) in order to determine if the allogeneic bone preservation process influences the amount of remaining particles and newly formed bone in maxillary sinus augmentation. MATERIALS AND METHODS: Subjects requiring maxillary lateral sinus augmentation with ridge height < 5 mm were included in this study. Maxillary sinuses were randomly assigned to be grafted with a 1:1 ratio of cortical and cancellous bone, either SDHA or FDHA. In both groups, the graft material was mixed with autogenous bone graft at a ratio of 1:1. Morphologic and histomorphometric analyses were completed 6 months after the grafting procedure. RESULTS: Thirty-four subjects were included in this study. All subjects showed similar demographic characteristics at baseline. Half of the sinuses were grafted with SDHA; the remaining half were grafted with FDHA. Histomorphometric analysis of bone core biopsy samples showed no statistically significant difference between the SDHA or FDHA allogeneic bone substitutes (P = .365), with a mean value of 39.54% ± 0.05% and 31.96% ± 0.08% of mineralized tissue for SDHA and FDHA, respectively. However, a slightly higher mean value of remaining particles was obtained for the FDHA compared with SDHA (18.91% ± 0.09% vs 8.65% ± 0.06%, respectively), although the difference was not statistically significant. Additionally, FDHA demonstrated statistically significantly higher osteoblast, fibroblast, and inflammatory cell numbers. CONCLUSION: Regardless of the preservation process subtype, allogeneic bone grafting material, in combination with autogenous bone, was demonstrated to be effective for maxillary sinus augmentation bone by means of cellular, vascular, and histomorphometric behavior. Nonetheless, FDHA demonstrated higher cellularity compared to SDHA, suggesting accelerated turnover activity for the latter grafting material.

Incidence of and Factors Associated with Sinus Membrane Perforation During Maxillary Sinus Augmentation Using the Reamer Drilling Approach: A Double-Center Case Series.

Maxillary sinus membrane perforation has been reported as the most common intraoperative complication during sinus augmentation, potentially leading to postoperative infection and consequent loss of graft or even implant failure. Numerous anatomical factors have been demonstrated to affect membrane tearing. However, careful use of proper instrumentation, such as a reamer, seems to play an important role in minimizing the incidence of these complications. Hence, the aim of the present study was to (1) investigate the reliability of reamer drilling for lateral window preparation; (2) examine the incidence of membrane perforation; and (3) study the factors that might influence membrane perforation. Results from this study showed the safety and effectiveness of using a reamer to perform lateral window approach sinus augmentation. The sinus membrane perforation rate was found to be 12.5%. A slightly higher perforation rate was noted in thinner maxillary lateral walls (< 1.25 mm). The authors concluded that reamer drilling is a safe and effective alternate technique for opening the lateral window wall when the lateral wall thickness is ≥ 1.25mm.

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¿Es el desplazamiento discal sinónimo de patología articular temporomandibular? Correlación clínico-radiológica y prevalencia de trastornos internos en sujetos voluntarios asintomáticos / Is disc displacement synonymous with temporomandibular joint pathology? Clinical-radiological correlation and prevalence of internal disorders in asymptomatic volunteers subjects

INTRODUCCIÓN: Los trastornos internos (TI) de la articulación temporomandibular (ATM) constituyen la condición clínica articular más frecuente en pacientes con trastornos temporomandibulares (TTM). Presentes hasta en un 80-90 % de los casos sintomáticos, no se sabe por qué, su presencia en sujetos asintomáticos no causa dolor ni disfunción. En contraposición, una posición normal del disco ha sido descrita en un 16-23 % de pacientes sintomáticos. OBJETIVOS: Analizar la prevalencia de TI de la ATM en sujetos voluntarios asintomáticos y qué características clínico-radiológicas podrían favorecer su presencia o desarrollo. MATERIAL Y MÉTODO: Se diseñó un estudio descriptivo, observacional, transversal. Se seleccionaron 43 sujetos de una población de 253 residentes que realizaban su formación médica especializada. El estudio fue desarrollado en varias fases. Fase I: Anamnesis y examen clínico. Empleo del índice craneomandibular de Fricton (ICM); Fase II: Adquisición y evaluación de imágenes de Resonancia Magnética (RMN). Las imágenes fueron procesadas a formato DICOM 4.0 y evaluadas por dos examinadores externos. Fase III: Análisis morfoestructural de las ATM. Las imágenes de RMN fueron analizadas empleando el programa informático Osirix® V 3.5.1. RESULTADOS: Setenta y dos articulaciones (pertenecientes a 36 sujetos) fueron finalmente analizadas. La edad media fue de 28,39 ± 3,70 años con una distribución por sexos de 47,2 % hombres y de 52,8 % mujeres. El análisis inferencial mostró resultados estadísticamente significativos en relación con las variables sexo (p = 0,021), chasquido articular (p = 0,007), valor del ICM (p = 0,000296), morfología discal (p = 1,032 X 10-8), morfología condilar (p = 2,116 X 10-8), posición condilar en el interior de la ATM (longitudes posterior y superior, p = 5,385 X 10-9; p = 0,000245, respectivamente) y morfología de la fosa articular (p = 0,024). CONCLUSIONES: Existe una elevada prevalencia de TI de la ATM en los sujetos asintomáticos analizados. Ciertos criterios clínicos (chasquido articular) y radiológicos (morfología discal alargada/doblada, cóndilo y fosa aplanados y posición más posterior y craneal del cóndilo mandibular) podrían ser considerados como predictores o relacionados con la presencia de desplazamiento discal. El ICM podría constituir una herramienta útil en el diagnóstico de patología articular de la ATM

INTRODUCTION: Internal derangements (IDs) of the temporomandibular joint (TMJ) constitute the most common clinical joint condition in patients with temporomandibular disorders (TMDs). Present in up to 80-90 % of symptomatic cases, it is not known why, its presence in asymptomatic subjects does not cause pain or dysfunction. In contrast, a normal position of the disc has been described in 16-23 % of symptomatic patients. OBJECTIVES: To analyze the prevalence of IDs of the TMJ in asymptomatic voluntary subjects and what clinical-radiological characteristics could favor their presence or development. MATERIAL AND METHODS: A descriptive, observational, cross-sectional study was designed. Fortythree subjects from a population of 253 residents who performed their training program were selected. The study was carried out in several phases. Phase I: Anamnesis and clinical examination. Use of the Fricton Cranio-mandibular Index (CMI); Phase II: Acquisition and evaluation of Magnetic Resonance Imaging (MRI). The images were processed in DICOM 4.0 format and evaluated by two external examiners. Phase III: Morpho-structural analysis of the TMJs. The MRI were analyzed using the Osirix® V 3.5.1 Software. RESULTS: Seventy-two joints (belonging to 36 subjects) were finally analyzed. The mean age was 28.39 ± 3.70 years with a distribution by sex of 47.2% men and 52.8 % women. The inferential analysis showed statistically significant results in relation to the variables sex (p = 0.021), joint click (p = 0.007), CMI value (p = 0.000296), disc morphology (p = 1.032x10-8), condylar morphology (p = 2.116x10-8) and condylar position inside the TMJ ((posterior and superior lengths, p = 5.385x10-9; p = 0.000245, respectively) and morphology of the joint fossa (p = 0.024). CONCLUSIONS: A high prevalence of IDs in asymptomatic subjects is present in our study. Certain clinical (joint clicking) and radiological criteria (an elongated or bent disc morphology, a flattened condyle and fossa and a more posterior and cranial position of the mandibular condyle) could be considered as predictors or be related to the presence of disc displacement. The CMI could be a useful tool in the diagnosis of joint pathology of the TMJ

Schwannoma of tongue.

The schwannomas are nervous tissue tumors. We report a case of schwannoma of oral tongue. Because schwannomas are quite rare in the oral cavity, they are often not immediately included in the differential diagnosis of oropharyngeal masses, causing delay in identification and treatment. The definitive diagnosis requires histopathologic examination.

Functional reconstruction after subtotal glossectomy in the surgical treatment of an uncommon and aggressive neoplasm in this location: Primary malignant melanoma in the base of the tongue.

Primary malignant melanoma of the oral cavity is a rare neoplasm, especially on the tongue. We report a case of mucosal melanoma at the base of the tongue, an extremely rare location (only about 30 cases have been reported in literature). The extension study doesn´t revealed distant metastatic lesions. The patient was treated by subtotal glossectomy and bilateral functional neck dissection. Tongue is one of the most difficult structures to reconstruct, because of their central role in phonation, swallowing and airway protection. The defect was reconstructed with anterolateral thigh free flap. Surgical treatment was supplemented with adjuvant immunotherapy. The post-operative period was uneventful. At present, 24 months after surgery, patient is asymptomatic, there isn´t evidence of recurrence of melanoma and he hasn´t any difficulty in swallowing or phonation. Key words:Malignant mucosal melanoma, anterolateral thigh free flap, phonation, swallowing.

Mucormycosis of the head and neck: report of five cases with different presentations.

Mucormycosis is a lethal fungal disease with a general poor prognosis. Rhinocerebral presentation is the more frequent form. The purpose of this study was to review and show our experience in the management of 5 cases of mucormycosis of the head and neck with different clinical presentations. The high suspicion led us a prompt diagnosis and aggressive surgical treatment that allowed a good outcome in our series.

Giant cell granuloma of the maxilla. Global management, review of literature and case report.

Giant cell granuloma is a relatively rare benign entity but can be locally aggressive. Histologically characterized by intense proliferation of multinucleated giant cells and fibroblasts. Affects bone supported tissues. Definitive diagnosis is given by biopsy. Clinically manifest as a mass or nodule of reddish color and fleshy, occasionally ulcerated surface. They can range from asymptomatic to destructive lesions that grow quickly. It is a lesion to be considered in the differential diagnosis of osteolytic lesions affecting the maxilla or jaw. Its management passed from conservative treatment with intralesional infiltration of corticosteroids, calcitonin or interferon, to the surgical resection and reconstruction, for example with microvascular free flaps. Key words:Giant cell granuloma, intralesional injection, microvascular free flap, fibula.

Bifosfonatos e implantes dentales, ¿son incompatibles? Revisión de la literatura / Are bisphosphonates and dental implants compatible? A review of the literature

Introducción. La osteonecrosis de los maxilares ha sido descrita en pacientes que toman bifosfonatos y han sido sometidos a cirugía dentoalveolar. Actualmente, la terapia con bifosfonatos e implantes dentales es un tratamiento muy común en adultos. Objetivos. Evaluar, a través de una revisión de la literatura, si la osteointegración del implante dental podría disminuir en pacientes que toman bifosfonatos orales o intravenosos. Además, se analiza el riesgo que tienen estos pacientes de desarrollar osteonecrosis de los maxilares. Material y métodos. Se realizó una búsqueda a través de la base de datos Medline (PubMed) de los artículos publicados en inglés en los últimos 15 años que incluyeran las palabras clave «bisphosphonates and dental implants», «bisphosphonates and orthopaedic implants» y «osteonecrosis of the jaws and dental implants». Conclusiones. El tratamiento con bifosfonatos no disminuye la osteointegración del implante dental, aunque estos resultados se han obtenido en base a estudios retrospectivos en humanos. Se han descrito casos de osteonecrosis de los maxilares relacionada con bifosfonatos en estos pacientes, sobre todo tras tratamiento prolongado (AU)

Introduction. At present, treatment with bisphosphonates and dental implant therapy are frequently used in adults. Bisphosphonate-related osteonecrosis of the jaws has been described in patients with bisphosphonate medication who underwent dentoalveolar surgery. Objectives. The aim of this study was to evaluate, through a literature review, whether osseointegration of dental implants could decrease in patients on intravenous or oral bisphosphonates. The risk of developing bisphosphonate-related osteonecrosis of the jaws in these patients was also analysed. Material and methods. A search was performed to find the most recent scientific literature (the last 15 years) using PubMed database, with the keywords «bisphosphonates and dental implants», «bisphosphonates and orthopaedic implants» and «osteonecrosis of the jaws and dental implants». Conclusions. Based on the current literature, it is concluded that bisphosphonate treatment does not decrease osseointegration of dental implants. Nevertheless, these results have been obtained in a retrospective in humans. Bisphosphonate-related osteonecrosis of the jaws has been described in patients on prolonged treatment (AU)