Recent Advances in Temporomandibular Joint Surgery.

Temporomandibular disorders (TMDs) affect a high percentage of children and adults worldwide. Surgery may be indicated in severe or recalcitrant cases. Several recent advancements in TMD and temporomandibular joint (TMJ) surgery have elevated understanding and the ability to treat affected patients. We discuss recent advances in TMD epidemiology, juvenile idiopathic arthritis (JIA) of the TMJ, and surgical techniques and technologies. Technical advancements have been identified in TMJ arthroscopy, the treatment of TMJ subluxation and dislocation, and extended prosthetic total TMJ reconstruction (eTMJR). Overall, this review provides valuable insights into significant recent advancements in TMJ disorders and their surgical management.

Persistent foramen of Huschke: Presentation, evaluation, and management.

OBJECTIVE: Describe the presentation and management strategy for patients with symptomatic foramen of Huschke (FH). PATIENTS: Adults with persistent FH confirmed on imaging. INTERVENTIONS: Diagnosis and management of symptomatic persistent FH. MAIN OUTCOME MEASURE: Resolution of otologic symptoms. RESULTS: A total of four patients with symptomatic, radiographically-confirmed persistent FH were included. The majority of patients endorsed otalgia (n = 4) and otorrhea (n = 3), and only one patient was noted to have a conductive hearing loss. All patients were noted to have dynamic movement of an external auditory canal mass with mandible manipulation on examination, and all patients had an identifiable fistula on imaging. Patients underwent surgical intervention, including both preauricular (n = 2) and transcanal (n = 2) approaches, and all endorsed symptomatic resolution after convalescence. CONCLUSIONS: Persistent FH remains an uncommon and potentially underrecognized cause of otologic symptoms. Diagnosis requires a high index of suspicion, and one must rely on both key examination findings and imaging to confirm this diagnosis. In appropriately selected patients, surgical intervention can provide durable symptomatic resolution. LEVEL OF EVIDENCE: IV.

Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019).

PURPOSE: The safety of the team anesthesia model routinely used by the specialty of oral and maxillofacial surgery has recently been called into question. The purpose of this article is to measure the frequency of adverse anesthetic events related to ambulatory surgical procedures performed under intravenous (IV) sedation by the Division of Oral and Maxillofacial Surgery at the Mayo Clinic during a 15-year period using the team anesthesia model. MATERIALS AND METHODS: A retrospective cohort study was designed, and a sample of subjects identified undergoing IV sedation at Mayo Clinic from 2004 to 2019. The primary outcome variable of interest was the presence of anesthetic-related adverse events (AEs) consistent with the World Society of Intravenous Anesthesia International Sedation Task Force's intervention-based definitions of adverse anesthetic events. Additional covariates included patient age, gender, American Society of Anesthesiologists (ASA) score, type of surgical procedure performed, and the type/dosage of medications administered periprocedurally. Univariate logistic regression analysis was used to assess for associations between AEs and covariates. RESULTS: The study identified 17,634 sedations administered to 16,609 unique subjects. In 17,634 sedations, 16 (0.1%) AEs and no subject deaths (0%) were identified. There were no statistically significant associations between AEs and age (hazard ratio [HR], 0.4; 95% confidence interval [95% CI], 0.2 to 1.3; P = .13); gender (HR, 0.9; 95% CI, 0.3 to 2.5; P = .87); ASA 2 classification (HR, 1.6; 95% CI, 0.6 to 4.5; P = .33); ASA 3 classification (HR, 1.3; 95% CI, 0.1 to 22.0; P = .86), or types of IV sedation medications administered during the procedure: fentanyl (HR, 0.4; 95% CI, 0.02 to 6.3; P = .5); midazolam (HR, 1.0; 95% CI, 0.2 to 4.3; P = .98); propofol (HR, 1.0; 95% CI, 0.3 to 3.5; P = .99); or ketamine (HR, 1.0; 95% CI, 0.1 to 7.3; P = .97). CONCLUSIONS: The frequency of AEs (0.1%) and 0% mortality rate reported in this study demonstrate that the anesthesia team model used by oral and maxillofacial surgeons compares favorably to standardized intervention-based adverse anesthetic event outcomes reported by other nonanesthesiology specialties routinely performing outpatient procedural sedation.

Does the Amount of Screw Fixation Utilized for the Condylar Component of the TMJ Concepts Total Temporomandibular Joint Reconstruction Predispose to Hardware Loss or Postoperative Complications?

PURPOSE: To determine whether the number of screws used to fixate a TMJ Concepts total joint prosthesis correlates with loss of hardware fixation or postoperative complications. MATERIALS AND METHODS: A retrospective cohort study of patients undergoing total temporomandibular joint (TMJ) reconstruction with the TMJ Concepts custom prosthesis at the Mayo Clinic from 2005 to 2015 was undertaken. The primary predictor variable was the percentage of screw fixation used in the condylar component. The primary outcome variable was loss of hardware fixation. Secondary outcome variables included postoperative wound infection, removal of hardware, and return to the operating room. Covariates abstracted included patient demographics, comorbidity indices, preoperative occlusion, contralateral TMJ reconstruction, performing surgeon, duration of procedure and anesthesia, intraoperative fluid administration, concomitant surgical procedures, perioperative antibiotics, prior TMJ surgeries, prior Proplast Teflon implantation, prior head and neck radiation, use of heterotopic ossification radiation protocol, and use of the 2 most superior screw holes in the condylar component. RESULTS: The study sample was composed of 45 patients representing 64 TMJ Concepts reconstructions. Mean age was 49.1 years (standard deviation, 13.4 yr; range, 19 to 85 yr). The female distribution was 86%. There were 15 simultaneous bilateral reconstructions, 26 unilateral reconstructions, and 4 staged bilateral reconstructions. Eighteen reconstructions (28%) were placed using 100% of the available screw holes in the condylar component. Forty-six reconstructions (72%) were placed using fewer than 100% of the available screw holes in the condylar component (range of screw fixation, 56 to 89%). The minimum number of screws used to fixate the condylar component was 5, which was observed in 9 reconstructions (14%). There was no postoperative loss of hardware fixation in any reconstruction under study. Six reconstructions showed a postoperative complication defined by the secondary outcomes. Univariable or multivariable modeling was precluded for the primary and secondary outcomes owing to the low frequency of observed complications. CONCLUSION: Fixating the condylar component of the TMJ Concepts total joint prosthesis using fewer than 100% of the available screw holes does not predispose the reconstruction to hardware loss, particularly if greater than 50% screw fixation can be achieved or a minimum of 5 screws are used.

Does Intravenous Midazolam Dose Influence the Duration of Recovery Room Stay Following Outpatient Third Molar Surgery?

PURPOSE: To evaluate the impact of intravenous midazolam dose on the duration of recovery room stay for patients undergoing outpatient third molar surgery. MATERIALS AND METHODS: Using a retrospective cohort study design, a sample of patients undergoing outpatient third molar surgery under intravenous sedation at Mayo Clinic from 2010 to 2014 was identified. All patients underwent extraction of all 4 third molars during a single operative procedure and the age range was limited to 14 to 29 years. The primary predictor variable was the total dose of intravenous midazolam administered during sedation. The primary outcome variable was recovery room length of stay (LOS) after completion of surgery. Multiple covariates also abstracted included patient age, gender, American Society of Anesthesiologists (ASA) score, duration of surgical procedure, complexity of surgical procedure, types and dosages of all intravenous medications administered during sedation, and volume of crystalloid fluid administered perioperatively. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary outcome variable. RESULTS: The study sample was composed of 2,610 patients. Mean age was 18.3 years (SD, 3.0 yr; range, 14 to 29 yr) and gender distribution was 52% female. Mean dosage of midazolam administered was 4.1 mg (SD, 1.1 mg; range, 0.5 to 10.0 mg). Variables predicting shorter LOS at multivariable analysis included older age (P < .001), male gender (P = .004), and administration of larger crystalloid fluid volumes (P < .001). Variables predicting longer LOS included higher ASA score (P < .001), administration of ketamine (P < .001), and administration of ketorolac (P < .001). The dose of midazolam administered during sedation was not found to be significantly associated with prolonged recovery room LOS in univariable or multivariable settings. CONCLUSION: Dosage of intravenous midazolam does not appear to significantly impact the duration of recovery room stay in the prototypical patients undergoing sedation for outpatient third molar surgery.

Dental extraction in the neutropenic patient.

PURPOSE: To identify risks of dental extraction in patients with mild, moderate, and severe neutropenia. MATERIALS AND METHODS: The authors undertook an observational study of 116 patients diagnosed with neutropenia and undergoing dental extractions in the Mayo Clinic Division of Oral and Maxillofacial Surgery. Absolute neutrophil count (ANC) was no higher than 1,500/µL. Predictors were ANC, age, diagnosis, number of teeth removed, type and location of extraction, length of antibiotic use, presence and type of bacteremia at the time of consultation or extraction, reason for consultation, indication for extraction, and use of any granulocyte colony-stimulating factor (GCSF). Primary outcomes were total complications, surgical site infections, delayed healing, and prolonged postoperative pain. Descriptive and bivariate analyses were undertaken, with statistical significance set at a P value less than or equal to .05. RESULTS: One hundred sixteen patients underwent extraction while neutropenic. The overall complication rate was 8.6% (n=10). All were minor complications requiring simple interventions, if any. Complications were delayed healing, surgical site infection, and prolonged postoperative pain. Delayed healing was not associated with ANC. GCSF and related medications did not appear to affect outcomes in these patients. CONCLUSION: The results of this preliminary study suggest that extraction of teeth in patients at all stages of neutropenia can be conducted safely. Complications of extraction were few and should be easily controlled. Further studies are required to clarify and stratify risk for future patients.

Late revision or correction of facial trauma-related soft-tissue deformities.

Surgical approaches used in accessing the facial skeleton for fracture repair are often the same as or similar to those used for cosmetic enhancement of the face. Rarely does facial trauma result in injuries that do not in some way affect the facial soft-tissue envelope either directly or as sequelae of the surgical repair. Knowledge of both skeletal and facial soft-tissue anatomy is paramount to successful clinical outcomes. Facial soft-tissue deformities can arise that require specific evaluation and management for correction. This article focuses on revision and correction of these soft-tissue-related injuries secondary to facial trauma.

Dental extraction in the thrombocytopenic patient is safe and complications are easily managed.

PURPOSE: To characterize bleeding risk and management of bleeding in thrombocytopenic patients undergoing dental extraction. MATERIALS AND METHODS: This retrospective cohort study included 68 patients with hematologic disease and concomitant thrombocytopenia undergoing dental extractions. The inclusion criterion was a platelet count of 100,000/µL or less at the time of consultation or extraction. Patients using anticoagulation therapy were excluded from the study. Predictors measured were age, gender, platelet count, platelet transfusion before or during surgery, local hemostatic measurements at the time of surgery (absorbable hemostat or antifibrinolytic rinse), number of teeth extracted, diagnosis, and extraction type. The primary outcome was postoperative bleeding requiring intervention. A secondary outcome was surgical site infection. Descriptive and bivariate statistics were computed and the P value was set at .05. No logistic regression was used based on the distribution of outcomes. RESULTS: Sixty-eight patients underwent extraction of 200 teeth. Five (7.4%) had postoperative bleeding that was always controlled with routine intervention. Mean platelet count was 44,647/µL. Bleeding was more frequent with lower platelet levels (P = .048). Thirty-two patients received platelet transfusion and 26 received local measures. Platelet transfusion and local hemostatic measures had no effect on bleeding outcomes. CONCLUSION: Surgical and routine extractions are safe procedures in patients with thrombocytopenia, and postoperative bleeding is typically well handled with simple local measures. The benefits of pre- or intraoperative platelet transfusion are unclear in this population. Likewise, the benefit of prophylactic local hemostatic measures is unclear and should be based on the surgeon's discretion and experience.

Chief resident case experience and autonomy are associated with resident confidence and future practice plans.

PURPOSE: To measure oral and maxillofacial surgery (OMS) chief resident case experience, including autonomy, and discover the role of this experience in developing resident confidence and determining the scope of practice on completion of training. MATERIALS AND METHODS: A cross-sectional study was conducted using an online questionnaire made available to residents near the completion of their final year of training in United States OMS training programs. Predictors were the case numbers and autonomy level. Outcomes were the anticipated frequency of practice, confidence to meet the standard of care, and changes in anticipated practice scope. Each was measured in 10 domains within the scope of OMS. RESULTS: Eighty-four residents (44%) completed the 116-item questionnaire. All respondents were "very confident" in their ability to meet the standard of care in mandibular trauma and dentoalveolar surgery. Autonomy was associated with the confidence to meet the standard of care in midface trauma, temporomandibular joint, orthognathic, cosmetic, pathology, reconstructive, and craniofacial surgery. Associations were noted between primary surgeon cases and confidence in midface trauma, temporomandibular joint, orthognathic, cosmetic, and craniofacial surgery. Case numbers were associated with an anticipated frequency of practice within the domains of midface trauma, temporomandibular joint, cosmetic, and pathology surgery. CONCLUSIONS: Results of this study suggest an association between a resident's surgical case experience (overall exposure and autonomy) and that resident's future plans for practice and confidence to meet the standard of care in this specialty. OMS training curricula should evolve to incorporate an evaluation of competence and an appropriate transfer of responsibility and experience to residents, thus maximizing confidence and future practice opportunities.

Polyelectrolytes as new matrices for secondary ion mass spectrometry.

Significant enhancements in ion yields in time-of-flight secondary ion mass spectrometry (TOF-SIMS) are observed when water-soluble analytes are mixed with a polyelectrolyte, e.g., poly(diallyldimethylammonium chloride) or poly(sodium 4-styrenesulfonate), and then deposited in the layer-by-layer method on a surface. This previously unobserved effect is demonstrated for 5-chloro-8-methoxyquinoline appended diaza-18-crown-6, 5-(2-aminoethoxy)methyl-5-chloro-8-methoxyquinoline appended diaza-18-crown-6, acridine, 9-anthracenecarboxylic acid, and ferrocenecarboxylic acid. By optical ellipsometry film thicknesses range from ca. 5-20 angstroms. X-ray photoelectron spectroscopy shows significantly less analyte in the polyelectrolyte-analyte films than in the neat analytes. However, TOF-SIMS generally shows significant enhancements in ion yields from the polyelectrolyte films compared with either the neat compounds or the compounds solubilized with acid or base and then dried on a surface. These significant enhancements in ion yields also appear to extend to analyte fragments and cationized molecular species. Some enhancement is also observed for dried droplets of analytes mixed with a polyelectrolyte on surfaces.

First reaction of a bare silicon surface with acid chlorides and a one-step preparation of acid chloride terminated monolayers on scribed silicon.

Methyl-terminated and acyl chloride terminated monolayers are produced when silicon is scribed under mono- and diacid chlorides, respectively. To the best of our knowledge, this is the first report of the reaction between a bare silicon surface and acid chlorides. This reaction takes place by wetting the silicon surface in the air with the acid chloride and scribing. Scribing activates the silicon surface by removing its passivation layer. We propose that scribed silicon abstracts chlorine from an acid chloride to form an Si-Cl bond and that the resulting acyl radical diffuses back to the surface to condense with the surface and form an alkyl monolayer. X-ray photoelectron spectroscopy (XPS) confirms the presence of chlorine and shows a steady increase in the amount of carbon with increasing alkyl chain lengths of the acid chlorides. Time-of-flight secondary ion mass spectrometry shows SiCl(+) species and a steady increase in representative hydrocarbon fragments with increasing alkyl chain lengths of the acid chlorides. XPS indicates that diacid chlorides react primarily at one of their ends to create acyl chloride terminated surfaces in a single step. The resulting surfaces are shown to react with various amines (piperazine, morpholine, and octylamine) and a protein. Calculations at Hartree-Fock and density functional theory levels are consistent with the proposed mechanism.