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.

Comparison of microstructures between block grafts from the mandibular ramus and calvarium for horizontal bone augmentation of the maxilla: a case series study.

The primary purpose of this clinical study was to compare architectural metric parameters using microcomputed tomography (micro-CT) between sites grafted with blocks harvested from the mandibular ramus and calvarium for horizontal bone augmentation in the maxilla. The second aim was to compare the primary stability of implants placed in both types of block grafts. Ten consecutive healthy partially edentulous patients requiring extensive horizontal bone reconstruction in the maxilla were included. A total of 14 block grafts (7 each from the mandibular ramus and calvarium) were studied. After 4 to 6 months of healing, 41 implants were placed: 24 implants (58.5%) in calvarial (group 1) and 17 (41.5%) in ramus grafts (group 2). A resonance frequency analysis (RFA) was performed to test implant stability. Furthermore, two biopsy specimens were randomly selected for histomorphometric analysis. Micro-CT analyses showed no significant difference in the morphometric parametric values analyzed between groups. Furthermore, RFA also showed no difference between groups. However, slightly higher RFA values were noted for implants placed in ramus grafts. Bone quality, as assessed by micro-CT and histomorphometric analyses, was similar in both ramus and calvarial block grafts. In addition, there was no difference in primary implant stability between groups.

Characteristics of newly formed bone in sockets augmented with cancellous porous bovine bone and a resorbable membrane: microcomputed tomography, histologic, and resonance frequence analysis.

AIM: Microcomputed tomography (micro-CT) has become a highly accurate and nonintrusive method for analysis of bone. This study aims to determine the microstructural characteristics of the bone formed in grafted extraction sockets. METHODS: This prospective study comprised 10 patients. Cancellous porous bovine bone (CPBB) was used for socket grafting. Ten bone samples were harvested from implant site 9 months after grafting, before implant placement, and histologic and microstructural characteristics were analyzed. Cone-beam computed tomography scans were performed, and implant stability was also determined. RESULTS: Four men and 6 women, with a mean age of 44 years, were included in the study. Micro-CT revealed a compact structure with high bone volume fraction, trabecular thickness and number, but a low trabecular separation and pattern factor, which made it an optimal structure that is expected to resist occlusal loads. Histologic examination revealed an abundant amount of CPBB particles (27.5%) and new bone formation (23.3%) 40.6 months after bone grafting surgery. Moreover, mean implant stability quotient was 75.7 units. CONCLUSION: This investigation demonstrated marked de novo bone formation after a healing period of 9 months. This trabecular bone had a compact structure with abundant thick trabeculae.

Comparison of implant primary stability between maxillary edentulous ridges receiving intramembranous origin block grafts.

PURPOSE: The purposes of the present study were: to compare the resonance frequency analysis (RFA) values of implant placed in either ramus or calvaria block grafts; and to determine if implant diameter influences RFA implant stability quotient (ISQ) value. MATERIAL AND METHODS: This was a retrospective study that included 16 consecutives healthy patients treated with autogenous onlay block grafts for horizontal bone reconstruction in maxilla. Ten ramus and ten calvaria block graft treated patients were selected and compared. RESULTS: Totally, 59 implants were placed, 35 (59.3%) were placed on the calvaria bone grafts and the remaining 24 (40.7%) were on the ramus bone graft. Of all the implants studied, 13 (22%), 35 (59.3%), and 11 (18.6%) were 10 mm, 11.5 mm and 13 mm in length respectively. Regarding the diameter, 4 (7%) were 3.3 mm, 3 (5%) were 3.5 mm, 20 (34%) were 3.7 mm and 32 (54%) were 4 mm. Mean ISQ value obtained by RFA was 73.06 ± 6.08, being 72.19 ± 6 and 74.47 ± 6.06 for the calvaria and ramus treated group respectively. No significant differences were noted between the two groups (p= 0.154). Implants were pooled and divided by their diameter. Mean ISQ value obtained for 3.3 mm was 80 ± 5.09, while for 4.0 mm was 72.5 ± 7.19. Again, no significant differences were found among the groups (p= 0.138). CONCLUSION: For RFA ISQ value, the bone graft origins (calvaria or ramus) or implant diameters did not influence the outcome.

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.

Hyperplasia of the mandibular condyle: clinical, histopathologic, and treatment considerations in a series of 36 patients.

PURPOSE: Mandibular condylar hyperplasia (CH) is a rare entity that causes overdevelopment of the mandible, creating functional and esthetic problems. The aim of this article was to describe demographic and clinical characteristics of CH, analyze histopathologic features and their association with scintigraphic and clinical findings, and evaluate esthetic and functional results after treatment by high condylectomy during the active phase. MATERIALS AND METHODS: This retrospective study included 36 patients whose condyles were removed because of excessive unilateral growth resulting in facial asymmetry and occlusal disturbance. Of the 36 patients, 13 had had symptoms related to the temporomandibular joint, such as pain or clicking. In all the cases, high condylectomy was performed, and surgical specimens were sent for histologic examination and divided into 4 histologic types as described by Slootweg and Müller. Statistical analysis was performed by use of R software (version 2.10.1; R Foundation for Statistical Computing, Vienna, Austria) and SPSS software for Windows (version 15.0; SPSS, Chicago, IL) to evaluate our results. A χ(2) test was carried out to assess the possible association between gender and involved side. The association of histologic appearance with clinical symptoms was estimated by use of the Fisher exact test. An analysis of variance test was performed to evaluate a possible association between patient age and histologic type according to the Slootweg and Müller classification and between histologic type and uptake on bone single photon emission computed tomography (SPECT). RESULTS: We could not find a relationship between histologic type and uptake of the affected condyle on bone SPECT or between age and histologic type. However, our statistical analysis revealed an association between histologic appearance and the presence of joint symptoms (P = .0049). Clinically, occlusion and facial symmetry improved in all patients postoperatively, and no recurrence was noted in any patient. Six patients required secondary surgery. CONCLUSION: We could not find any significant association between age and histologic type or between bone SPECT and histologic type. However, a significant association between histologic type and temporomandibular joint symptoms was observed. High condylectomy combined with orthodontics achieved optimal esthetic and functional results and constituted the unique and definitive treatment in 30 of 36 patients.

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.