"Phoenix jaw"-bone regeneration of the necrotic mandible between pathological fractures: an unusual but evocative course of bisphosphonate-related osteonecrosis.

Management of advanced bisphosphonate-related osteonecrosis of the jaw, particularly in cases of pathological fractures with extraoral fistulas, is a challenging responsibility for craniomaxillofacial specialists. Although a periosteal reaction is occasionally observed in cases with extensive sequestra, few reports have documented circumferential periosteal osseous formation resulting in bone repair. We present the case of a 78-year-old woman who was treated for breast cancer and received intravenous bisphosphonates. She had bisphosphonate-related osteonecrosis of the jaw with bilateral pathological fractures of the mandible. During the course of minimally invasive treatment, the necrotic segment was separated with circumferential exposure, and new bone spontaneously formed with osseous union to the unilateral fractured stump. The present case typically highlights the potential of periosteal osteogenesis to regain an acceptable state even for patients with severe "bis-phossy jaw," particularly those with pathological fractures, although we do not advocate the universality of the phenomenon presented as "phoenix jaw."

Life-threatening oronasal hemorrhage managed by transcatheter embolization of bilateral maxillary arteries in an elderly patient with comminuted LeFort I fracture.

Massive orofacial hemorrhage mostly occurs in younger individuals unilaterally and is associated with extensive LeFort fractures. Here we describe a 91-year-old man who sustained a life-threatening hemorrhage of the bilateral internal maxillary artery (IMA) system with a comminuted LeFort I fracture caused by a road traffic accident while he was driving. His injury severity score was high (34), but no severe brain injury was sustained. Transarterial embolization (TAE) was performed to control the intractable hemorrhage. The patient survived and has an acceptable outcome. Although rare, this case may be representative of a trend in maxillofacial injuries in the elderly resulting from worldwide motorization and steady aging of more active populations. Life-threatening hemorrhage of the bilateral IMA system occurs even in LeFort I fractures. Controlling an intractable oronasal hemorrhage with TAE would lead to survival with less severe morbidity, even for the very elderly with no severe brain injuries.

Nodular fasciitis in the buccal region with rapid growth after incisional biopsy mimicking sarcoma.

Nodular fasciitis (NF) is a reactive and proliferative fibroblastic lesion that occurs predominantly in the upper limbs but rarely develops in the oral cavity. This lesion can be misdiagnosed as malignant owing to its frequent display of rapid growth, rich cellularity, and high mitotic activity. Unlike a sarcoma, NF can resolve spontaneously or after an incisional biopsy. We describe a challenging case involving a lesion in the buccal region that rapidly enlarged after incisional biopsy. This variation of clinical behavior illustrates the difficulty in predicting whether NF will continue to grow or regress. Clinicians dealing with cases of an enlarging fibrous lesion of short duration should remain aware of this disease entity and its potential diagnostic dilemma.

Necrotizing sialometaplasia in a patient with an eating disorder: palatal ulcer accompanied by dental erosion due to binge-purging.

This report describes a case of necrotizing sialometaplasia (NS) accompanied by significant dental erosion of the maxillary teeth of the palatal surfaces owing to chronic self-induced vomiting. This observation contributed to the determination of an immediate and appropriate provisional diagnosis of NS in a patient with an eating disorder, which subsequently was confirmed histopathologically as NS. The diagnostic challenges presented by NS associated with eating disorders and its management are discussed.

Closed reduction of mandibular condyle fractures using C-arm fluoroscopy: a technical note.

We describe a C-arm technique for mandibular condylar fractures in an anatomic study using a model skull and show its feasibility in a clinical case. The C-arm allowed posterior-anterior visualization of the condylar process. The X-ray axis was canted ∼15 degrees cranially to the Frankfort horizontal line. The skull's sagittal plane was rotated ∼15 degrees ipsilaterally to the X-ray axis. This technique facilitates clear visualization of the condylar neck with easy, flexible, and timely adjustments. In selected cases, this method would convert the clinical settings of the condylar fracture pattern to that which would not be amenable to an open approach, making possible minimally invasive surgical procedures.

C-arm-guided reduction of zygomatic fractures revisited.

BACKGROUND: Anatomic reduction of the zygomatic arch, a key surgical landmark for midfacial width and projection, is essential for the treatment of combined fractures of the zygomaticomaxillary complex and zygomatic arch. Reduction control in surgery for this common facial fracture would be facilitated by intraoperative real-time assessment using widely available and reliable equipment. Although C-arm fluoroscopy is routinely used in the repair of orthopedic fractures, its use in the maxillofacial region, particularly for combined zygomatic fractures, has been scarcely reported. METHODS: We prospectively evaluated C-arm-guided reduction in 38 patients of combined zygomatic fracture without concurrent craniofacial fractures. Patients were classified according to the presence or absence of bone contact in the displaced zygomatic arch, namely as conserved (C) and loss (L) types, respectively. Reduction status was determined by the degree of recovery of the malar prominence and arch shape. RESULTS: In all cases, C-arm imaging clearly displayed the displaced zygomatic arch and body in a single image. Cumulative fluoroscopic time was a few minutes in all cases. Total reduction status was excellent in 21 patients and good in 17. No case was classified as fair or poor. Repair was significantly more favorable in type C than in type L cases (p = 0.0016). CONCLUSIONS: In combined zygomatic fractures, the C-arm technique provides easy, flexible, and time-efficient adjustment. Its comprehensive imaging for zygomatic arch shape and body contour markedly facilitates the control of fracture reduction and protects against unexpected, unsatisfactory outcomes.

NK cell lymphoblastic lymphoma in the masticator space: a case of non-Hodgkin lymphoma with challenging maxillofacial manifestation and immunophenotype.

Clinical and pathologic findings in extranodal non-Hodgkin lymphoma (NHL) often raise challenging problems in diagnosis. We demonstrate the first established case of lymphoma with precursor natural killer (NK) cell origin in the oral and maxillofacial region. An 81-year-old Japanese man had an enlarged facial mass mainly in the parotid region but hyposensitivity in the affected side of the mental and lingual region, and diagnostic imaging revealed the origin to be in the masticator space and indicated an advanced-stage lymphoma. The tumor cell immunophenotype was CD56(+)CD3(-)CD4(-), with no B-cell- or myeloid-associated markers. The genotype was of the germ-line configuration of T-cell receptor genes, and no association with Epstein-Barr virus was evident, leading to a diagnosis of NK-cell lymphoblastic lymphoma. This report discusses diagnostic challenges of NHL, including manifestation of numb chin syndrome as a clinical indicator and immunophenotyping of NK-cell-lineage neoplasms.

Bilateral multiple spindle cell lipomas of the tongue.

Spindle cell lipoma (SCL) typically occurs in elderly men as a solitary lesion in the posterior neck and back, but less commonly also involves the oral cavity. Here, we describe a rare case of bilateral multiple SCLs of the tongue. The patient was a 72-year-old Japanese man with multiple painless soft nodules in the bilateral margins of the tongue. The patient was not obese, and had used alcohol moderately for more than 40 years. A clinical diagnosis of multiple tongue lipomas was made. The tumors were resected surgically, and they exhibited the histopathological features of SCL, composed of mature fat cells, collagen-forming CD34-positive spindle cells, and sparse mast cells. This suggests that differential diagnosis of intraoral multiple lipomatous nodules should include not only lipomatosis but also multiple SCLs, notwithstanding the rare incidence of the latter.