Facial reconstruction after pre maxillary resection in a bilateral cleft lip and palate patient - a case report Technologies for resection and reconstruction of mandibular lesions.

Loss of the premaxilla is a rare event while treating patients with bilateral cleft lip and palate. Its resection is no longer an acceptable method of treatment in modern practice. Nowadays, most cases of premaxillary loss are secondary to treatment and manipulation of the premaxilla, and not due to intentional resection. In the following case presentation we present the treatment of a seven years old boy, presented to our institution after being treated for bilateral cleft lip and palate by resection of the premaxilla. Through a series of operations including bone grafting, distraction of the maxilla, and cartilaginous graft we managed to reconstruct a proper facial habitus, a convex facial profile and nasal projection. Restoring the bony structure of the face is a significant challenge. Due to the complex three dimensional anatomy, the presence of critical structures and the variety and uniqueness of each deficiency it is essential to form the optimal surgical plan and to execute it precisely. Development of computer aided manufacturing (CAD/ CAM - computer assisted design / computer assisted manufacturing) and advances in manufacturing technologies and material science brought a whole array of options and tools for the purpose of planning and performing computer assisted surgery. CAD/CAM technology allow for various application: Manufacturing of a physical anatomical model, Using the 3D model for hardware pre-bending, Manufacturing of cutting jigs and intraoperative fixation templates, Manufacturing of custom made implants. The surgeon may choose which of the application to use in any specific case or combine all of these abilities according to the complexity of the case. Two cases presenting the applications of these technologies will be reviewed.

Oral surgery-associated postoperative bleeding in haemophilia patients - a tertiary centre's two decade experience.

Our goal in this research was to evaluate potential and targeted therapy, correlated with haemophilia severity and dental procedural risk, to reduce postoperative bleeding risk. Patients with haemophilia who were treated at the Oral and Maxillofacial Surgery Clinic at Sheba Medical Center between 1996 and 2012 comprised the study cohort. Data collected included disease history and severity, perioperative factor concentrate therapy, local haemostatic agent application, systemic tranexamic acid use and outcome. Bleeding was defined as excessive bleeding during or within 20 days following procedure. Dental procedures (n = 1968) of 125 patients were studied. Patients' bleeding risk score was evaluated according to the severity of haemophilia with or without the presence of an inhibitor, presence of comorbid coagulopathy and the type of dental procedure. Thirty-four patients undergoing a total of 880 high-risk and 1088 low-risk procedures suffered 40 postoperative bleeding events that necessitated further dental and/or haematological intervention. Among risk factors for delayed bleeding, the use of fibrin glue was significantly (P = 0.027) associated with the risk of postprocedural bleed probably as it was applied to high-risk patients and procedures. Earlier treatment period (P = 0.055), postprocedure hospitalization (P = 0.039) and dental "high-risk" procedures (P < 0.0001) also increased bleeding risk. Patients with haemophilia may be safely treated if meticulous haemostasis is applied, along with fibrin glue and systemic therapy as required. Factor transfusions are not mandatory and should be applied considering the procedure-related risk and the patient's calculated haematological risk for bleeding.

The incidence and nature of complaints against dentists for the treatment of children in Israel from 1992-2011.

OBJECTIVES: Medical literature lacks information about complaints against dentists who treat children. The present study aimed to evaluate the reports filed to Medical Consultant International (MCI) regarding paediatric dentistry in 1992-2011. BASIC RESEARCH DESIGN: Most dentists in Israel (85%) are obliged by their professional liability insurance policy to report adverse events to MCI. Reports were analysed using a structured form that included demographic details of the treating dentist, patients and parents, type of treatment, the result and the dentist's attitude. MCI dental consultants' decisions were evaluated by two specialists in paediatric dentistry. RESULTS: The number of complaints per year is increasing. Complaints involved maltreatment (33%), case mismanagement (25%) and complications that required additional treatment (26%). Communication was problematic in 60% of cases. Only 16.7% of complaints developed into an actual lawsuit. Most complaints were against female general practitioners and against dentists who worked in community dental clinics located in peripheral areas. Treating permanent teeth increased to 3.6 times the probability of developing into a lawsuit. 59% of event records had missing data. Seventy-five percent of the cases rose from elective treatments while 25% concerned emergency treatments. One third of the cases required additional treatment in a hospital i.e. abscess drainage, foreign body swallowing or other physical damages. CONCLUSIONS: Better case selection and documentation, better training of dentists who treat children and more appropriate attitude toward patients and parents, are likely to reduce the number of complaints.

[Medicolegal aspects of iatrogenic root perforations].

AIM: To retrospectively analyze the medico-legal aspects of iatrogenic root perforations (IRP) that occurred during endodontic treatments. METHODOLOGY: A comprehensive search in a professional liability insurance database was conducted to retrospectively identify cases of IRP following root canal treatments (RCTs). The complaints were categorized as either financial risk bearing or financial nonrisk bearing, and related demographic and endodontic variables were analyzed. RESULTS: One hundred and twenty cases of patients with IRP were identified. Twenty six cases (22%) were elective RCTs, and 94 cases (78%) were endodontic treatments performed due to pathologic processes (p < 0.05). Sixty cases (50%) were identified in mandibular molars, significantly more than other tooth locations (P < 0.05). In 102 cases (85%) the outcome was extraction, and in 18 cases (15%) the outcome was an additional treatment (p < 0.05). For both the cases with outcome of extraction and for the cases with an additional treatment, the complaints were judged as financial risk bearing in 95% of the cases. CONCLUSIONS: latrogenic root perforation is a complication of root canal treatment and may result in tooth extraction and in legal actions against the treating practitioner. Mandibular molars are more prone to medico-legal claims related to root perforations. The patient should be informed of the risks during RCT and should get information on alternative treatments and their risks and prognosis

Thrombocytopenia and bleeding in dental procedures of patients with Gaucher disease.

The risk of bleeding during dental procedures may be increased in patients with Gaucher disease. We aimed to evaluate potential coagulation and platelet function abnormalities and targeted therapy accordingly. Patients with type 1 Gaucher disease who were treated at the Oral and Maxilo-Facial surgery clinic at Sheba Medical Center between 2003 and 2010 comprised the study cohort. Data collected included disease history, enzyme treatment, platelet counts, dental therapy and outcome. Bleeding was defined as excessive bleeding during or immediately following procedure. Coagulation studies and platelet function tests including aggregometry were performed on all patients. Dental procedures (n = 14, including eight teeth extractions, two crown lengthening procedures, one cyst enucleation and three deep dental scaling) of seven patients were studied. Mean platelet count prior to procedure was 73 K ± 14.8 mm(3). Patients bleeding risk score was calculated according to previous history of bleeding tendency, degree of thrombocytopenia, presence of comorbid coagulopathy and the type of dental procedure. Two patients with highest risk score received prophylactic platelet transfusions, three patients (medium-risk) received DDAVP preprocedure and all received systemic tranexamic acid, which was the only systemic therapy for low-risk patients. Meticulous surgical local haemostasis was applied. No excessive intra-operative or postoperative bleeding occurred. Patients with Gaucher disease who have thrombocytopenia and abnormal platelet function tests may be safely treated if meticulous haemostasis is applied along with systemic therapy as required. Platelet transfusions are not mandatory and should be applied considering the procedure-related risk and the patient's calculated haematological risk for bleeding.

Medico-legal aspects of vertical root fractures in root filled teeth.

AIM: To analyse the medico-legal aspects of vertical root fracture (VRF) following root canal treatment (RCT). METHODOLOGY: A comprehensive search in a professional liability insurance database was conducted to retrospectively identify cases of VRF following RCT. The complaints were categorized as either financial risk bearing or financial nonrisk bearing, and related demographic, prosthetic and endodontic variables were analysed. RESULTS: Seventy-seven legal cases of patients with VRFs following RCT were identified. Most of the cases were either in premolars or in mandibular molar teeth (P<0.05). Poor-quality root filling was associated with an extended delay of diagnosis (P<0.05). The presence of a post significantly increased the financial risk assessment (P<0.05). CONCLUSIONS: Poor quality root fillings complicate the diagnosis of VRF, which in turn extends the time for achieving an accurate diagnosis and increasing the medico-legal risk. Premolar and mandibular molar teeth were more prone to medico-legal claims related to VRF following RCT. Post should be placed only when essential for additional core support to avoid medico-legal risk.

[Dental management of patients using anti agregant drugs: background, risks and clinical guidelines].

The object of this review is to juxtapose the risk of discontinuing anti-thrombotic therapy versus the benefit of less bleeding during dental procedures. The use of anti-thrombotic therapy to prevent cardiovascular thrombotic events is fundamental in the treatment of arterial sclerosis. Aspirin and Clopidogrel (Plavix) are the two anti-thrombotic drugs mainly used for this purpose. In patients with a history of symptomatic arteriosclerotic heart disease, aspirin therapy reduces the risk of myocardial infarction. Since the risk of recurrent cardiovascular event is known to be higher during the first few months following a symptomatic cardiovascular event, optimal treatment during this period is crucial. Any patient suffering from symptomatic arteriosclerosis should receive permanent anti-thrombotic therapy, unless strongly contraindicated. Poor compliance with or discontinuation of the anti-thrombotic therapy is associated with higher risk for a cardiovascular events. The risk of a cardiovascular event increase 3-4 days after discontinuation of anti-thrombotic therapy. A conventional dental treatment does not normally cause massive bleeding in patients using antithrombotic therapy. There is no evidence to support discontinuation of antithrombotic therapy prior to dental procedures. Therefore, considering the importance of anti-thrombolitic therapy in ateriosclerotic patients and the risk involved in discontinuing this therapy on the one hand, and the low risk of significant bleeding during dental procedures in patients using anti-thrombotic therapy on the other hand, one should be extra cautious in discontinuing antithrombotic therapy before dental procedures. Our recommendations are detailed in the article.

Localized myofascial pain responds better than referring myofascial pain to botulinum toxin injections.

Myofascial pain of the muscles of mastication is a common temporomandibular disorder. Patients unresponsive to conservative treatment modalities pose a therapeutic challenge to the treating clinician. The efficacy of intramuscular botulinum toxin injections for recalcitrant cases is still not well established due to mixed results from clinical trials. The Diagnostic Criteria of Temporomandibular Disorders (DC/TMD) classified chronic muscle pain broadly into a localized pattern (when pain is localized to the site of palpation or the muscle palpated) and a referring pattern (when the pain spreads beyond the boundary of the muscle being palpated). The medical records of 25 consecutive patients treated with botulinum were analysed retrospectively. Significant pain reduction was achieved in 69.2% of the patients with localized myofascial pain and 16.7% of the patients with referring myofascial pain (P=0.015). Seventy-seven per cent of the patients with localized myofascial pain reported using less analgesic throughout the follow-up period, whereas only 25% of the patients with referring myofascial pain (P=0.017). The effects of botulinum toxin in responsive patients subsided after a mean of 3.21 months. Patients with localized myofascial pain benefited from botulinum toxin injections, but patients with referring myofascial pain responded poorly to this treatment.

Emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region.

BACKGROUND: The edentulous interforaminal mandibular area is frequently the preferred area for implant placement. METHODS: A case of emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region is described. The probable cause was bleeding from the sublingual artery or a branch of that artery following implant perforation of the lingual cortex. RESULTS: Healing was uneventful and the patient was released from the hospital after 11 days. Three years later, CT showed a well-osseointegrated implant with a severe buccolingual inclination. CONCLUSIONS: It is stressed that short implants (14 mm or less) should be used in the mandibular canine region and that effective treatment of this complication is essential.

Burkitt's lymphoma mimicking an acute dentoalveolar abscess.

Burkitt's lymphoma is a monoclonal proliferation of B lymphocytes classified histologically as a poorly differentiated lymphocytic lymphoma. The jaw and retroperitoneal structures are the most commonly involved sites. Prognosis is highly dependent on the stage of the disease. In some cases, the first manifestation of Burkitt's lymphoma is in the jaws, and symptoms may be misdiagnosed as infection. Dental radiographs can play an important role in the diagnosis. A case of a peculiar Burkitt's lymphoma involving the mandible that was misdiagnosed as an acute dentoalveolar abscess is presented.

Osteosarcoma of the jaw. The Chaim Sheba Medical Center experience.

OBJECTIVE: The purpose of this article is to present 14 cases of osteosarcoma of the jaw treated at our medical center from 1989 to 1998. These cases are discussed in the light of a comprehensive review of 774 cases reported in the English literature over the past 3 decades. Differences between osteosarcoma of the jaws and osteosarcoma of the long bones are examined. SUBJECTS AND METHODS: The patients ranged in age from 8 to 78 years, the mean age being 33 years. Each patient had a histopathologically established diagnosis of osteosarcoma of the jaw. Records were reviewed for epidemiologic data, treatment modalities, and survival. RESULTS: Of the 14 patients, 6 (42%) had tumors in the mandible and 8 (58%) had tumors in the maxilla. Of the mandibular tumors, 5 occurred in the body of the mandible; all maxillary tumors originated in the alveolar ridge and involved the maxillary sinus. The chief complaint was an intraoral or extraoral painless swelling. Histopathologic types included chondroblastic, osteoblastic, fibroblastic, and malignant fibrous histiocytoma-like. Pathologic grade was determined to be high (3 or 4) in 13 cases and low (1) in only 1 mandibular case. All patients underwent surgical resection and immediate reconstruction. Adjuvant therapy included postoperative radiation (5 patients), postoperative chemotherapy (2 patients), and preoperative chemotherapy and postoperative radiation (1 patient). CONCLUSIONS: The results of the present study support the literature indicating that osteosarcoma of the jaw differs from osteosarcoma of the long bones in its biological behavior even though they have the same histologic appearance. Because of differences in tumor characteristics, the introduction of chemotherapy did not dramatically alter the prognosis of osteosarcoma of the jaw. Early diagnosis and radical surgery are the keys to high survival rates.

[Sport-related maxillofacial fractures].

The records of 537 patients with 750 maxillofacial fractures were reviewed and analyzed. 55 (10.2%) had sport-related injuries and the rest were due to other causes. The sport-related group was predominantly male (ratio 9:1) with a mean age of 24.5 years. The mandible was most commonly injured (52.5%), followed by the zygomatic complex (32.8%). The incidence of complicated mid-facial fractures was only 2.8%, and of comminuted fractures 9%. This distribution of injuries is most likely due to the relatively low-energy of trauma associated with many sport activities. The relatively low mean age of the patients, most of whom had full dentition, allowed for conservative treatment of most of the mandibular fractures, using closed reduction. Injuries were caused by 11 different sports. The highest incidence was soccer (45%), followed by skating (15%), basketball (9%) and horse-riding (9%). Contact sports were the cause of injuries in 72.2%, with the highest incidence of trauma due to impact with another player (60%). Better protection of the oral and maxillofacial region is needed, especially during high-contact sport.

Radiological features of osteogenic sarcoma of the jaws. A comparative study of different radiographic modalities.

OBJECTIVE: To evaluate the clinical and radiological features of osteogenic sarcoma of the jaws with particular reference to the effectiveness of the radiographic modalities used. MATERIAL AND METHODS: A total of 66 cases (57 from the English-language literature and nine new cases) were critically evaluated for the features depicted with intra-oral and panoramic radiography and CT. RESULTS: The mean age of the patients was 36 years (median 31.5 years). There were no differences in gender distribution. A ratio of 1:1.6 between the maxilla and the mandible was found. Lesions had diffuse borders in 78% of cases and defined but not corticated borders in 22%. Twenty-nine per cent were radiolucent, 29% radiopaque and 41% mixed density. Widening of the periodontal ligament space (PDL) was seen in 14 of the 47 (28%) lesions associated with teeth and structural changes in the mandibular canal in 34% of the mandibular lesions. There was a periosteal reaction in 48% and soft tissue involvement in 33% of the lesions. CONCLUSIONS: Widening of the PDL space was best demonstrated on periapical radiographs. Structural changes in the mandibular canal were shown mainly with panoramic radiographs. Periosteal reaction was best demonstrated by occlusal radiographs and soft tissue involvement by CT. Thorough radiological examination using periapical, occlusal and panoramic radiography, and recognition of the radiological features of osteogenic sarcoma should lead to earlier diagnosis.

Changing indications for tracheostomy in maxillofacial trauma.

PURPOSE: Tracheostomy is one of the most common surgical procedures, but not always without complications. The purpose of this article was to reevaluate the indications of maintaining the airway with the use of tracheostomy. MATERIALS AND METHODS: A total of 399 patients with maxillofacial trauma, who were treated in the Maxillofacial Surgery Department from 1985 to 1992, were evaluated for the type of fracture and air-way problems. RESULTS: Out of the 399 patients evaluated, 13 needed a tracheostomy. Of these, 6 had had a cricothyroidotomy on arrival, 3 required tracheostomy because of impending airway obstruction, 3 because of respiratory distress, and 1 due to difficulty in intubation. CONCLUSIONS: The results of this study indicated that surgically securing the airway by tracheostomy should be revised compared to other available methods. In the era of rigid fixation of fractures and the possibility of leaving the patient with an open mouth, it is unnecessary to carry out tracheostomy for securing the airway as frequently as in the past.

Vigabatrin-induced gingival overgrowth.

Vigabatrin is a relatively new medication used in the treatment of epilepsia. The present report concerns the use of vigabatrin by a 19-year-old woman. The patient manifested marked gingival overgrowth compatible clinically and histologically with the overgrowth induced by phenytoin, cyclosporine and calcium channel blockers. This is the 1st report of vigabatrin-induced gingival overgrowth. Clinicians should be aware of similar lesions in patients using new anticonvulsants.