Ecthyma gangrenosum: A case report in a child with acute lymphoblastic leukaemia.

Aim: We present a case of Ecthyma gangrenosum (EG) affecting left thigh in a child with acute lymphoblastic leukaemia (ALL) with an aim to raise awareness about this condition. Case presentation: A 7-year-old female child who presented with lethargy, pallor and lumps to inner lip was diagnosed with B-cell precursor ALL. She was started on treatment as per UKALL 2011 guidelines Regime B. On day 28, she developed neutropenic sepsis along with a new lesion in her left thigh. She was started on intravenous Meropenum, Gentamicin and Caspofungin. The clinical diagnosis of EG was made based on lesion progression, positive blood and wound swab & tissue cultures for Pseudomonas aeruginosa and patient's immunocompromised status. The wound healed with secondary intention following debridement. We present a series of photographs to demonstrate her remarkable improvement. Discussion: EG occurs in 1-30% of cases of Pseudomonas sepsis; other bacteria and fungi can be associated with this condition. It is identified more in oncology patients as seen in our patient. A multidisciplinary team approach should be provided in 3 stages with empirical antibiotics, followed by targeted antibiotics or antifungals & surgical debridement. Our patient was treated in similar fashion and made a good recovery. Conclusion: It is a rare skin condition associated with a high mortality. We suggest all clinicians to be vigilant about this condition to be able to provide accurate diagnosis and prompt treatment to improve the overall prognosis.

Effect of different advancement positions on the maximum retrusive force of the mandible.

INTRODUCTION: Functional appliances lead, in different degrees, to loss of anchorage in the lower arch. By anchoring them to the mandibular bone, any dental side effects may be avoided and the skeletal effect enhanced. Stability of bone-borne fixation would be affected by forces created by the pull of the masticatory muscles. We aimed to identify mean maximum forces produced by mandibular retrusive muscles, at different degrees of advancement. SUBJECTS AND METHODS: Eighteen healthy adult volunteers participated in the study. Maximum retrusive force was measured using a splint/load cell system. Readings of the maximum forces of retrusion were taken from five mandibular positions: unstrained retruded position, and 4, 5, 6, and 7 mm anterior to the unstrained position. Data were presented as means ± SD and anova was performed to examine statistical significant differences between means of the maximum retrusion force. RESULTS: Mean maximum retrusion force ranged between 63.3 and 198.2 newtons at the unstrained and 7 mm positions, respectively. It increased as the distance of advancement increased, being statistically significantly (p < 0.05) less at unstrained position compared with all advancement distances, 4 mm of advancement than 6 and 7 mm advancement, 5 mm of advancement than at 7 mm advancement. CONCLUSION: Magnitude of the forces exerted by muscles during voluntary maximum retrusion movement from different advancement positions increased proportionately as the retrusion distance increased up to 7 mm. Such range of high forces might be important to consider when designing a bone-borne functional appliance.

Routine four-quadrant cavity shaving at the time of wide local excision for breast cancer reduces re-excision rate.

INTRODUCTION: Breast conservation therapy (BCT) has been shown to have comparable long-term survival outcomes when compared with mastectomy. Clearance of excision margin is one of the mainstays of the surgical treatment, which if not achieved at the first operation of BCT results in the need for subsequent surgery. METHODS: This study evaluated the impact of routinely taken cavity shavings on re-excision rates. This retrospective two-centre study describes the use of routine four-quadrant cavity shaving in 449 patients with consecutively treated with wide local excision for invasive cancer or ductal carcinoma in situ. RESULTS: The overall incomplete excision rate was 10.6%. Routine cavity shaving prevented the need for re-excision in 84 patients (18.7%) and identified the need for further re-excision in 33 patients (7.3%). Median time from surgery to radiotherapy was 50 days (range 13-209) for non-re-excised patients versus 78 days (range 47-260) for re-excised patients (p<0.001). Median time to chemotherapy (n=75) was 44 days (range 14-106) for non-re-excised patients versus 56 days (range 35-116) for re-excised patients (p=0.017). CONCLUSIONS: This study demonstrates that routine cavity shaving decreases re-excision rate in patients treated with wide local excision and prevents delays to adjuvant treatment due to incomplete excision.

Emergency management of dental trauma: knowledge of Hong Kong primary and secondary school teachers.

OBJECTIVES. To investigate the level of knowledge about emergency management of dental trauma among Hong Kong primary and secondary school teachers. DESIGN. Questionnaire survey. SETTING. A teachers' union that unites 90% of teachers in Hong Kong. PARTICIPANTS. Randomly selected primary and secondary school teachers. RESULTS. Only 32.8% of respondents correctly stated that a person sustaining dental trauma should go to dentists directly. In all, 73.1% of teachers correctly stated that a dental trauma patient should go for treatment immediately. Only 32.5% knew that a fractured tooth should be put in liquid. Even fewer (23.2%) realised that the displaced tooth should be repositioned back to the original position. Relatively more respondents (74.7%) understood that an avulsed baby tooth should not be put back. Disappointingly, only 16.3% of teachers knew that an avulsed permanent tooth should be replanted. Furthermore, only 29.6% of teachers thought that they were able to distinguish between deciduous teeth and permanent teeth, whilst 20.4% correctly identified at least one of the appropriate mediums: milk, physiological saline or saliva, for storing an avulsed tooth. Teachers who previously received first-aid training with dental content or acquired dental injury information from other sources, scored significantly higher than teachers without such training or acquired information. CONCLUSION. The knowledge on emergency management of dental trauma among primary and secondary school teachers in Hong Kong is insufficient, particularly on the handling of permanent tooth avulsion and the appropriate storage medium for avulsed teeth. Receipt of first-aid training with dental contents and acquisition of dental injury information from other sources were positively correlated with knowledge in managing dental trauma.

Traditional Chinese medicine and oral diseases: today and tomorrow.

With a history of over 2000 years, traditional Chinese medicine (TCM) evolves into a unique system of diagnosing and treating illnesses. It is a challenge to convey the fundamentals of this traditional medicine to our Western colleagues because of the differences in language, philosophy and concept of diagnosis and treatment. This review attempts to tackle these barriers by introducing several widely used Chinese medicines for treating oral diseases. China Journals Full-text Database and Pubmed were used as the searching engines. Although many studies have demonstrated that the Chinese medicines are effective in treating oral diseases including recurrent aphthous stomatitis, oral lichen planus, leukoplakia, and Sjögren's syndrome, most of them lacked standard criteria of post-treatment assessment and laboratory evidence. Randomized controlled clinical trials with specific assessment criteria are required to close the gap between TCM and evidenced-based medicine.

High-rhythm automatic driver for bone traction: an experimental study in rabbits.

The distractors currently used in clinics are activated manually by intermittent advancement. An automatic driver has been developed to attach to custom-made or commercially available distractors and activate advancement at a high rhythm of 8 steps per second. One 1.5-V lithium button battery is used as the power source to drive a step motor and the driving torque is transmitted to the distractor through a flexible shaft at a rate of 2 revolutions per day. This automatic driver was tested in 5 rabbits for mandibular lengthening. Osteotomy was performed on one side of the mandible and the custom-made distractor was adapted. After a latency period of 3 days, the automatic driver was attached to the distractor's arm and mandibular lengthening was activated. After 11 days of continuous distraction the automatic driver was detached from the distractor's arm. All the rabbits were euthanized after 4 weeks of consolidation. The distraction regenerates were analysed by plain radiography, micro-computerized tomography and histological examination. All 5 rabbits completed the experimental process and healed uneventfully. The mandibles were confirmed to have lengthened successfully and the distraction gap was filled with newly formed bone.

Stability and morbidity of Le Fort I osteotomy with bioresorbable fixation: a randomized controlled trial.

A randomized controlled clinical trial was conducted to compare the use of bioresorbable and titanium mini-plates and screws in Le Fort I maxillary osteotomies for evaluation of clinical morbidity and stability. Forty patients requiring Le Fort I osteotomies were randomly assigned to two groups. One group underwent bioresorbable mini-plate fixation and the other titanium mini-plate fixation. Stability of the maxilla was determined by serial cephalometric analysis at 2 and 6 weeks and at 3, 6 and 12 months postoperatively. Subjective and objective assessment of clinical morbidity was made prospectively. There were no differences in complications between the two fixation materials. Maxillae with bioresorbable fixation were significantly more mobile at the second postoperative week. Bioresorbable plates were initially more easily palpable, but their palpability decreased with time. Titanium plates became significantly more palpable at the 1-year follow-up. There was no difference in neurosensory disturbance between groups. Patients with bioresorbable plate fixation showed significantly more upward displacement in anterior maxilla following impaction and posterior maxilla following downgrafting from the 2nd to 6th postoperative week. The horizontal and angular relapses in the two groups were comparable. Le Fort I osteotomy with bioresorbable fixation results in no greater morbidity than with titanium fixation up to 1 postoperative year.

A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis.

This meta-analysis aims to provide evidence-based data to assist surgeons to make an informed choice between distraction osteogenesis or conventional osteotomy for cleft lip and palate patients. A PUBMED search of the National Library of Medicine from 1966 to December 2003 was conducted. Keywords used in the search were 'cleft', 'distraction', 'maxilla', 'maxillary', 'advancement', 'osteotomy', and 'orthognathic surgery'. This study concluded that distraction osteogenesis tends to be preferred to conventional osteotomy for younger CLP patients with more severe deformities. In such cases it was feasible to use distraction to correct moderate to large movement of the maxilla by either complete or incomplete Le Fort I osteotomy, and a concurrent mandibular osteotomy was less frequently required. Intra-operative and post-operative complications were uncommon with either technique, and some of the traditional ischemic complications related to conventional osteotomy were replaced by infection of the oral mucosa due to the prolonged retention of the distractors. There is still no conclusive data on any differences in surgical relapse, velopharyngeal function and speech between the two techniques. Both distraction osteogenesis and conventional osteotomy can deliver a marked improvement in facial aesthetics.

A comparison of post-operative complications following wisdom tooth surgery performed with sterile or clean gloves.

This randomised prospective study aimed at evaluating possible differences in the post-operative complication rate following lower wisdom tooth surgery performed with either sterile or clean surgical gloves. The microbiological profiles of the tooth sockets and glove surfaces were also evaluated and compared. A total of 275 ASA I, non-smoking and non-drinking patients consented to be randomly assigned into two groups for lower wisdom tooth surgery, performed by operators wearing either sterile or clean gloves. All the patients returned for a post-operative assessment visit one week later. An additional 40 patients were recruited and randomised into the sterile glove group (n = 20) or the clean glove group (n = 20) for the microbiology study. Specimens were taken from the glove surfaces and the post-operative socket wounds during wisdom tooth surgery. This clinical trial showed no significant difference between the sterile and clean glove groups in the incidence of acute inflammation, acute infection and dry sockets in the wounds. No single peri-operative factor had a statistically significant effect on post-operative pain intensity. Most of the bacterial isolates from the clean gloves were Gram-positive cocci or spore-forming bacilli. The total number of colony forming units and the variety of bacterial isolates from the socket wounds in the sterile and clean glove groups were similar. The study concluded that there was no advantage in using sterile surgical gloves rather than clean gloves to minimize post-operative complications in wisdom tooth surgery. There was also no apparent relationship between the bacteria contaminating the clean glove surfaces and those isolated from the socket wounds.

Flow cytometric analysis of DNA ploidy in hepatocellular carcinoma.

To examine the prognostic and pathobiologic significance of DNA content, the authors studied the surgically resected hepatocellular carcinomas of 69 patients by flow cytometric analysis. Homogeneity of DNA content within individual tumor nodules was present in 15 (88%) of 17 specimens examined. Similarly, homogeneity of DNA content in tumors having multiple nodules was found in 8 (73%) of 11 specimens. In 64 tumors with homogeneous DNA content evaluated further, DNA aneuploidy was present in 30 (46.9%) specimens, and the proportion of aneuploid tumors was similar in the large (> 5 cm in diameter, n = 35) and small (< or = 5 cm, n = 25) lesions, at 42.9% and 40%, respectively. Overall, the diploid tumors had serum alpha-fetoprotein levels increased to greater than 500 micrograms/mL more frequently than did the aneuploid tumors (P = .037). DNA content did not correlate significantly with hepatitis B surface antigen, presence of liver cirrhosis, cellular differentiation, tumor size, or tumor encapsulation. DNA content also did not influence tumor invasiveness in terms of liver invasion, presence of tumor microsatellites, or venous permeation. With multivariate Cox regression analysis, tumor encapsulation (P = .015), negative resection margin (P = .007), and DNA ploidy pattern stratified according to large and small tumors (P = .024) were favorable prognostic factors. In the small tumors, a diploid DNA pattern was associated with significantly better patient survival than was an aneuploid pattern (P = .012). In the large tumors, on the contrary, a diploid pattern was associated with poorer patient survival than was an aneuploid pattern (P = .029). The authors conclude that DNA ploidy pattern in hepatocellular carcinomas is homogeneous and stable. It supplements other predictors in prognostication when the lesions are stratified into small and large ones by tumor size. It is of particular importance as a predictor because it can be assessed preoperatively in needle-biopsy specimens.

Use of flow cytometry in the analysis of stage III squamous cell carcinoma of the oesophagus and its association with MIB-1.

AIMS: To examine the prognostic and pathobiological importance of DNA content in oesophageal squamous cell carcinomas in Hong Kong Chinese subjects; to evaluate its association with the immunohistochemical proliferative marker MIB-1. METHODS: Paraffin wax embedded tumour tissue and adjacent normal tissue (control tissue) samples from 45 resected stage III oesophageal squamous cell carcinomas were studied using flow cytometric analysis. The DNA content and the clinicopathological data of these patients were analysed together with the MIB-1 labelling index. RESULTS: DNA aneuploidy was present in 14 (31%) of the 45 cases. However, the DNA content did not correlate significantly with the age, sex, or survival of the patients, nor the length, location, differentiation and MIB-1 labelling index of the oesophageal carcinomas. The synthetic (S) phase fraction of diploid tumours bore no relation to the patients' survival or MIB-1 score. CONCLUSIONS: Flow cytometry was not as useful as the MIB-1 labelling index in predicting the biological characteristics of the tumours and the prognosis of patients with oesophageal squamous cell carcinomas. This study does not support the routine use of DNA flow cytometric analysis in oesophageal cancers.

Bilateral transverse facial clefts and accessory maxillae--variant or separate entity?

We report an extremely rare case of bilateral transverse facial clefts and accessory maxillae with severe mandibular hypoplasia in a 7-year-old Chinese boy. The transverse facial clefts had been repaired in infancy. The accessory maxillae were excised via a combined temporal and oral approach. Functional orthodontic appliance therapy was not feasible due to restricted protrusive movements of the mandible. Bimaxillary osteotomies were performed one year later due to failure mandibular catch-up growth to occur. The pathogenesis of the accessory maxillae in the presence of lateral facial clefting is postulated to be compensatory mesenchymal growth from the temporal region, and a case is made for this condition to be considered as a possible syndrome rather than a variant of the transverse facial cleft.

The use of mouldable acrylic for restoration of the temporalis flap donor site.

Despite the wide popularity of the pedicled temporalis myofascial flap, aesthetic management of the temporalis donor site has received little attention. A technique for immediate camouflage of the temporalis flap donor site with cold-cure methyl methacrylate, either alone or in combination with residual muscle in the temporal fossa, is presented. A retrospective evaluation of this technique in 34 consecutive patients was undertaken, with particular reference to the aesthetic results and morbidity associated with the use of cold-cure acrylic for this form of reconstruction. Apart from transient postoperative swelling and neuropraxia, no major or lasting complications associated with the use of cold-cure acrylic were recorded. The aesthetics of the camouflaged temporalis donor site by acrylic alone, or when combined with part of the temporalis muscle, was judged objectively to be excellent in 25 patients, satisfactory in 3 patients, and poor in 2 patients. 4 patients who did not have acrylic reconstruction, but had part of the temporalis muscle transposed to conceal the anterior fossa depression, leaving the posterior fossa unreconstructed, were judged mostly as satisfactory. Histology of the soft tissues around an acrylic implant after nearly 2 years confirmed the good biocompatibility of this material. It is concluded that this technique is a safe and reliable method for immediate camouflaging of the temporal fossa after harvesting a temporalis muscle flap.

The vascular anatomy of the human temporalis muscle: implications for surgical splitting techniques.

Despite the wide application of the temporalis muscle flap and its modifications, understanding of the vascular pattern and territories within the muscle remains poor. This study aimed to evaluate the vascular architecture in the human temporalis muscle for surgical application. The material comprised 15 fresh cadavers (30 muscle specimens), which were divided into three groups for vascular infusion by either Indian ink solution, lead oxide solution, or methylmethacrylate resin. The vascular network in the temporalis muscle was analyzed by stereomicroscopy, radiography, and scanning electron microscopy. The human temporalis muscle was found to have vascular supply from three primary arteries: the anterior deep temporal artery (ADTA), the posterior deep temporal artery (PDTA), and the middle temporal artery (MTA). Each primary artery branched into the secondary arterioles and then the terminal arterioles. The venous network accompanied the arteries, and double veins pairing one artery was a common finding. The capillaries formed a dense, interlacing network with orientation along the muscle fibres. Arteriovenous anastomosis was absent. In the coronal plane, the vessels were located mainly on the lateral and medial aspects of the muscle with a significantly lower vascular density in the midline. Morphometric analysis of the arterial network showed that the PDTA was larger in size at primary and secondary branching levels than the ADTA and the MTA, whereas no differences were present at the terminal arteriolar levels. The distribution of the arterial territories was as follows: the ADTA occupied 21% anteriorly, the PDTA occupied 41% in the middle region, and the MTA occupied 38% in the posterior region. This improved understanding of the vascular architecture within the temporalis muscle complements the anatomic basis of the flap-splitting technique and increases the safety of its application.

The epithelialization process in the healing temporalis myofascial flap in oral reconstruction.

The aim of this study was to investigate prospectively the epithelialization process in the healing temporalis myofascial flap (TMF). Eight cats underwent maxillectomy and immediate reconstruction with TMF. They were killed at the determined time and the reconstructed maxillae were processed for examination by light microscopy and scanning electron microscopy. Results revealed that epithelialization of the healing TMF was initiated by hyperplastic changes followed by active migration of epithelial cells deriving from the wound margins. The partial maxillectomy wound was completely covered by a smooth oral mucosa at postoperative week 24. The mucosa had histological and ultrastructural features different from normal palatal mucosa.

Microvascular network of the healing surface over the temporalis flap in maxillary reconstruction.

This study aims to describe and quantify the microvascular changes of the healing wound in a maxilla reconstructed by a temporalis myofascial flap (TMF). 24 cats underwent partial maxillectomies and reconstruction by TME Vascular infusion was performed immediately following sacrifice and then analyzed by radiography, light and SEM. Results showed that the superficial microvascular layer overlying the TMF underwent a similar transformation as in the histological healing sequence. The vascular density was highest during the initial 6 weeks, followed by reducing density at the chronic inflammatory phase, to normal at the proliferative and remodelling phases. The migrating epithelium brought on a microvascular sub-epithelial plexus, which eventually covered the TMF. The finding that the vascular source of this sub-epithelial plexus comes from the surrounding tissues rather than from the underlying TMF will have surgical implications for bony reconstruction of the maxilla.

Oral midazolam sedation in third molar surgery.

A double-blind randomised study was designed to assess the value of oral midazolam in patients undergoing minor oral surgery. 30 young healthy Hong Kong Chinese with bilateral symmetrical impaction of lower third molars to be surgically removed in 2 visits, were included in the study. Randomly selected, a powdered midazolam tablet or placebo was given on the 1st visit and the alternative on the 2nd visit. 45 min were given for the drug to act. Surgical removal of the teeth was carried out by a single operator, randomly, one side being done at one visit. The majority who had midazolam were relaxed during the operation. Nearly 75% had partial to complete amnesia. Midazolam sedation lasted about 45 min, produced good operating conditions and stable vital signs with adequate verbal response. The main adverse effects were drowsiness and dizziness on the same day. The majority had never heard of oral sedation being available to supplement local anaesthesia. The majority preferred midazolam to placebo and preferred to have local anaesthesia supplemented with oral sedation for minor oral surgery in the future.

The buccal fat pad in oral reconstruction.

The use of the buccal fat pad (BFP) as an uncovered pedicled graft to close oral defects is relatively recent. A series of 29 consecutive cases of reconstruction utilizing the BFP is presented, showing excellent results and without added surgical morbidity. Indications include defects after benign or malignant tumour resection, and the combined BFP/temporalis myofascial pedicled flap is reported as an additional option in reconstruction. Histologic findings in healed reconstruction sites indicate fibrous replacement of the fat tissue, and epithelialization of its oral surface. From the results of this series, we conclude that the use of the BFP for the reconstruction of appropriate surgical defects in the mouth is worthy of consideration.

A comparison of alveolar bone grafting with and without simultaneous maxillary osteotomies in cleft palate patients.

Nineteen unilateral and 19 bilateral alveolar clefts (group A) were grafted with cancellous iliac bone by a standard method, and 21 unilateral and 15 bilateral clefts (group B) underwent simultaneous maxillary osteotomies and alveolar bone grafting with cancellous iliac bone. The two groups were retrospectively evaluated clinically and radiographically for alveolar bone level (ABL), attached keratinized gingiva (AKG), sulcus depth (SD), and persistence of oronasal fistulae (ONF). The follow-up ranged from 6 to 54 months with a mean of 23 months for group A and 26 months for group B. In group A, AKG ranged from 1 to 10 mm (mean 5 mm), most patients having deep or normal SD and type I ABL as measured according to the Oslo method. No persistent ONF was noted. In group B, AKG ranged from 0 to 8 mm (mean 3 mm), half the patients showing a shallow sulcus, most with type II or III ABL. In this group, a 4% failure rate of the bone grafting was noted and 6% fistula persistence. It is concluded that the overall results of standard alveolar bone grafting are better in this series than those of simultaneous osteotomy cases, results which are still quite acceptable because they are comparable with published results of standard alveolar bone grafting. The results of this study indicate that simultaneous osteotomy with alveolar bone grafting in cleft patients does not compromise the outcome of bone grafting; therefore, they support the one-stage surgical management of patients with ungrafted clefts and maxillary hypoplasia.

Immediate reconstruction following maxillectomy: a new method.

A new method for immediate reconstruction of the maxilla after resection is described. The ipsilateral pedicled temporalis muscle is tunneled into the defect and sagittaly split into two layers. The inner layer is used to line the nasal side. An individually shaped titanium mesh, tightly filled with free autogenous corticocancellous bone, is fixed by titanium screws to the remnant of the zygoma and contralateral maxilla. The outer layer of the split muscle covers the reconstruction, the temporalis fascia forming the oral side. The method resulted in good cosmetic appearance and permitted the re-creation of a maxillary alveolar ridge suitable for endosseous implants or a simple prosthesis.