Temporomandibular Joint: Approach to the Intermediate Space by Triangulation With Transillumination Reference.

Arthroscopy of the temporomandibular joint is a minimally invasive surgical procedure. Nowadays, 3 levels are described depending on the complexity. Level I involves a single puncture with an anterior irrigating needle for outflow. Level II involves a double puncture using triangulation in order to be able to perform minor operative maneuvers. Subsequently, it is possible to progress to Level III and perform more advanced techniques, through multiple punctures, involving the arthroscopic canula and 2 or more working cannulas. However, in cases of advanced degenerative pathology or re-arthroscopy, it is common to observe advanced fibrillation, severe synovitis, adhesions, or articular obliteration which makes conventional triangulation difficult. On these cases, we propose a simple and effective technique that facilitates approach to the intermediate space by means of triangulation with transillumination reference.

Improved Quality of Life After Mandibular Advancement by Bilateral Internal Ramus Distraction.

BACKGROUND: Obstructive Sleep Apnea (OSA) is a significant health issue due to noncompliance with continuous positive airway pressure treatment. Therefore, evaluating alternative treatments is crucial. PURPOSE: Analyze the impact of maxillomandibular advancement using bilateral internal ramus distraction (BIRD) on quality of life (QOL) in OSA patients. STUDY DESIGN, SETTING, AND SAMPLE: A prospective cohort study was conducted at the Oral and Maxillofacial Surgery Department of the University Hospital "La Princesa." The study included patients with moderate to severe OSA who were treated with the BIRD approach. PREDICTOR VARIABLE: Changes in measured variables were analyzed at three time points: before surgery (T1), after mandibular advancement (T2), and after maxillary advancement (T3). MAIN OUTCOME VARIABLE(S): QOL changes measured by Quebec Sleep Questionnaire and the Epworth Sleepiness Scale. Secondary outcomes included: apnea-hypopnea index (AHI), oxygen desaturation index, and percentage of time with saturation below 90%. COVARIATES: Age, sex, continuous positive airway pressure treatment, cephalometric variables and cardiovascular risk parameters were considered. ANALYSES: Statistical analysis employed the Friedman test and χ2 test, with a significance level of P ≤ .05. RESULTS: The study included 32 patients (22% with moderate OSA, 78% with severe OSA). Epworth Sleepiness Scale scores significantly decreased between T1 (13.4 ± 4.4) and T2 (5.8 ± 3.6) and T3 (1.9 ± 1.8) (P < .001). QOL improvements were observed in all domains: daytime sleepiness T1 (3.0 ± 1.3) T2 (5.4 ± 1.4) T3 (6.3 ± 1.0); diurnal symptoms T1 (2.5 ± 1.4) T2 (5.2 ± 1.3) T3 (6.2 ± 1.1); nocturnal symptoms T1 (2.5 ± 1.1) T2 (5.6 ± 1.1) T3 (6.5 ± 0.8); emotions T1 (2.6 ± 1.6) T2 (5.3 ± 1.4) T3 (6.5 ± 0.9); and social interaction T1 (2.5 ± 1.6) T2 (5.4 ± 1.6) T3 (6.3 ± 1.2) (P < .001). AHI decreased between T1 (47.9 ± 23.1) and T2 (14.4 ± 14.3) and T3 (4.7 ± 5.6) h-1 (P < .001), with a final cure rate of 81.2% (defined as final AHI<5 h-1). Oxygen desaturation index and percentage of time with saturation below 90% also showed significant reductions (P < .001). CONCLUSIONS AND RELEVANCE: BIRD approach for OSA demonstrated a high cure rate and significant QOL improvements. It shows promise as an effective surgical option. Further research and long-term follow-up are needed.

Zygomatic distraction osteogenesis for correction of midfacial support after hemimaxillectomy: experience and technical considerations.

PURPOSE: The maxilla is the functional and esthetic keystone of the midface, and large maxillary defects remain a challenge for reconstructive surgery. Different regional and microvascularized flaps have been used to restore the hemimaxilla. Distraction osteogenesis offers an alternative to complex flaps, with less donor-site morbidity. This method is also preferable as a secondary reconstruction in cases of serious bone defects where other flaps have failed. PATIENTS AND METHODS: Four patients with maxillary defects after oncologic ablation presented at a mean follow-up period of 36 months (standard deviation, 18 mo). In these patients, transport distraction osteogenesis of the zygoma was used to restore the bony support of the low maxilla. RESULTS: After a latency period of 15 days, distraction began at a rate of 0.5 mm/day. A 2-step distraction, by changing the direction of the zygomatic device, was carried out in 3 cases. After a consolidation period of 4 to 6 months for each distraction, the devices were removed and the bone edges were joined together with an autogenous bone graft (anterior iliac crest and calvaria). A good quality of bone was observed in the distracted gap, which allowed for postoperative dental implant placement and prosthetic rehabilitation. CONCLUSION: In patients with large maxillary defects in which the remaining bone is insufficient and in patients in whom other reconstructive methods have failed, zygomatic distraction is an excellent option to restore the low projection of the maxilla. Bone transport was found to be a stable reconstructive method that allowed for the restoration of function and esthetics in oncologic patients.

Osseointegrated implant rehabilitation of irradiated oral cancer patients.

PURPOSE: The aim of this study is to analyze implant survival in patients who received radiotherapy treatment for oral malignancies and in patients who had suffered mandibular osteoradionecrosis. MATERIALS AND METHODS: We reviewed retrospectively 225 implants placed in 30 patients who had received radiotherapy as part of the oncologic treatment. Radiation doses ranged between 50 and 70 Gy. 39 implants were placed after a combined treatment of radiotherapy and chemotherapy. Data referred to tumour type and reconstruction, presence of osteoradionecrosis, region of implant installation and type of prostheses were recorded. Survival rates were calculated with cumulative Kaplan-Meier survival curves and compared between different groups with a log-rank test. RESULTS: 152 osseointegrated implants were placed in patients who presented previous reconstruction procedure. Five patients developed osteorradionecrosis as a complication of the radiotherapy treatment. Once osteoradionecrosis had healed in these patients, 41 implants were installed. The overall 5 year survival rate in irradiated patients was 92.6%. Irradiated patients had a marginally significantly higher implant loss than non-irradiated patients. (p = 0.063). The 5 year survival rate in the osteoradionecrosis group was of 48.3% and in the non-osteoradionecrosis group 92.3%, with a statistically significant difference between both groups. (p = 0.002). CONCLUSION: Osseointegrated implants enhance oral rehabilitation in most irradiated patients, even being an acceptable option for patients who had suffered osteoradionecrosis. Totally implant supported prostheses are recommended after irradiation providing functional, stable and aesthetically satisfactory rehabilitation.

Arthroscopic lysis and lavage versus operative arthroscopy in the outcome of temporomandibular joint internal derangement: a comparative study based on Wilkes stages.

PURPOSE: To assess whether arthroscopic lysis and lavage (ALL) or operative arthroscopy (OA) is more effective for the treatment of temporomandibular joint (TMJ) internal derangement at any stage of involvement. PATIENTS AND METHODS: In 458 patients (611 joints) with internal derangement of the TMJ classified as Wilkes stages II through V, arthroscopy was performed. Pain (visual analog scale score, 0-100) and maximal interincisal opening were assessed at 1, 3, 6, 9, 12, and 24 months after surgery. RESULTS: ALL was performed in 308 of 611 arthroscopies (50.4%), and OA was performed in 303 arthroscopies (49.59%). A significant decrease in pain (P < .001) was observed for all patients at any time during the follow-up period from the first month postoperatively to the end of the 2-year follow-up period. A highly significant increase in mouth opening greater than 13 mm was observed in the group of patients classified as Wilkes stage IV from the first month postoperatively. When we compared ALL versus OA among Wilkes stages, no significant differences in terms of pain were observed during the entire follow-up period. CONCLUSIONS: Both ALL and OA are equally effective at decreasing pain in patients with TMJ internal derangement of any Wilkes stage. Patients classified as Wilkes stage IV presenting with chronic closed lock of the TMJ had the highest decrease in pain and the highest increase in mouth opening among the stages, thus confirming these patients as the best candidates for arthroscopy.

Vertical distraction osteogenesis of a free vascularized fibula flap in a reconstructed hemimandible for mandibular reconstruction and optimization of the implant prosthetic rehabilitation. Report of a case.

Free vascularized fibular flap is considered the treatment of choice in mandibular reconstruction for extensive bone defects (over 6 centimeters) resulting from trauma, infections or tumor resections. But, when the reconstruction involves a dentate mandible, the fibula has the limit as it does not offer sufficient bone height to restore the alveolar arch up to the occlusal plane. Therefore, the deficiency in bone height makes implant placement impractical. We report a case of vertical distraction osteogenesis of a free vascularized fibula flap used to reconstruct a hemimandible after resection of an odontogenic myxoma, for optimization of the implant prosthetic rehabilitation. The distraction device was applied intraorally. After 10 days of latency period, distraction protocol was performed at a distraction rate of 0.5 mm per day. A consolidation period of 3 months followed. Afterwards the distraction device was removed and 3 osseointegrated dental implants were placed in the distracted area. As a result, the vertical discrepancy between the fibula and the native hemimandible was corrected. The amount of vertical height achieved after distraction was 17 milimeters. The increase of vertical bone height was stable and enabled placement of dental implants without any complications. In conclusion, we consider that vertical distraction osteogenesis of free vascularized flaps is a reliable technique that optimizes implant positioning for ideal prosthetic rehabilitation, after mandibular reconstruction following tumor surgery.

Prognostic factors influencing contralateral neck lymph node metastases in oral and oropharyngeal carcinoma.

PURPOSE: The prognostic influence of different clinicopathologic factors in contralateral lymph node metastases of oral and oropharyngeal squamous cell carcinoma (SCC) has been rarely described in the literature. Prediction of these contralateral metastases may be of relevance because this factor is strongly associated with poor prognosis. This study analyzed the relationship between predictor factors and the development of contralateral metastases in oral and oropharyngeal SCC. MATERIALS AND METHODS: A series of 402 cases of oral and oropharyngeal SCC were analyzed retrospectively. Unilateral neck dissection was carried out in 190 patients, bilateral neck dissection in 101, and tumor resection without neck dissection in 111. The log-rank test was used for survival analysis of contralateral metastases. Correlation between different clinicopathologic factors and the presence of contralateral metastases was studied with the chi(2) test for univariate analysis and logistic regression for association of these factors and contralateral metastases in the multivariate analysis (P < .05). RESULTS: Of the patients, 20 (5.1%) had primary positive contralateral metastases in neck dissection specimens and 19 (4.8%) had contralateral recurrences at follow-up. When the 2 groups were taken into consideration, the rate of contralateral metastases of the series was 9%. Gender, tumor location, homolateral positive nodes, tumor extension across the midline, histologic grade, margin status, pattern of growth, and perineural spread were correlated with contralateral metastases in the univariate analysis (P < .05). However, homolateral lymph node metastases and extension across the midline were the most important predictors of contralateral metastases (P < .01) on multivariate logistic regression analysis. Positive contralateral metastases showed a strong correlation with a poor prognosis for survival in this study (P < .05). CONCLUSION: Oral and oropharyngeal carcinomas with homolateral positive lymph nodes and tumor extension across the midline are at higher risk of contralateral lymph node involvement. Prediction of contralateral metastases may be useful in planning more aggressive therapies in patients with head and neck SCC with poor prognostic criteria.

Influence of the upper joint surface and synovial lining in the outcome of chronic closed lock of the temporomandibular joint treated with arthroscopy.

PURPOSE: Temporomandibular joint (TMJ) arthroscopy has been reported to be an effective and reliable technique for the treatment of chronic closed lock (CCL) of the TMJ. The purpose of the present study was to evaluate whether the status of the joint surface and the synovial lining directly visualized with arthroscopy could determine postoperative results in patients with CCL of the TMJ. MATERIALS AND METHODS: In all, 257 of 500 patients (344 joints) fulfilled the inclusion criteria for CCL of the TMJ. Of these patients, 172 with unilateral TMJ involvement were finally selected for the study. Synovitis and chondromalacia were chosen as the main features for evaluation of the joint surface and synovial lining. Two groups of patients were established: 1) patients with scarce affectation (synovitis grades I-II and chondromalacia grades I-II); and 2) patients with severe affectation (synovitis grades III-IV and/or chondromalacia grades III-IV). Pain and maximal interincisal opening were chosen as dependent variables. All patients were assessed at 1, 3, 6, 12, and 24 months postoperatively. The paired-samples Student's t test was used to compare mean values for pain (using a visual analog scale) and maximal interincisal opening (MIO) both pre- and postoperatively. The Student's t test for unpaired data was applied for the statistical analysis. A P value less than .05 was considered statistically significant. RESULTS: Synovitis grades I-II were arthroscopically observed in 87 (50.58%) patients, whereas synovitis grades III-IV were present in 72 (41.86%) patients. Chondromalacia grades I-II were arthroscopically observed in 66 (38.37%) patients, whereas chondromalacia grades III-IV were present in 54 (31.39%) patients. A statistically significant decrease in pain (P < .001) with a parallel increase in mouth opening (P < .001) after arthroscopy was observed for patients with synovitis I-II, synovitis III-IV, chondromalacia I-II, and chondromalacia III-IV during the whole follow-up period. A significant difference (P = .01) in relation to VAS score was observed between patients with synovitis I-II and patients with synovitis III-IV at month 6 postoperatively. However, this difference did not persist during the rest of the follow-up period, as was the case in relation to mouth opening. No significant differences were observed in relation to decrease of pain and increase of MIO between patients with chondromalacia I-II and patients with chondromalacia III-IV at any time during the follow-up period. Although mean values for pain were lower in patients with synovitis I-II plus chondromalacia I-II in comparison to patients with synovitis III-IV plus chondromalacia III-IV for the whole follow-up period, no statistical significant differences were observed. In relation to the increase in mouth opening, slightly higher values were observed for patients with synovitis I-II plus chondromalacia I-II, although no statistical differences were observed with regard to patients presenting with synovitis III-IV plus chondromalacia III-IV. CONCLUSION: A significant decrease in pain with a parallel increase in MIO was achieved from month 1 postoperatively in patients with any grade of synovitis and/or chondromalacia. No statistical difference in pain or function was observed between patients with scarce involvement of the joint surface and the synovial lining and patients with severe involvement after arthroscopy.

Reconstruction of oromandibular defects by vascularized free flaps: the radial forearm free flap and fibular free flap as major donor sites.

PURPOSE: Since the advent of the modern microvascular techniques, the radial forearm free flap (RFFF) and the vascularized fibular free flap (VFFF) have become reliable methods for reconstructing oromandibular defects. The purpose of this study is to evaluate our experience with the use of both free flaps in the reconstruction of oral cavity defects after tumoral ablation. PATIENTS AND METHODS: Over a 9-year period, 103 consecutive patients were treated in our department for the reconstruction of oral defects after tumor ablation by means of microvascularized free flaps. A total of 55 patients underwent reconstruction using RFFFs; 42 patients underwent reconstruction using VFFFs with or without skin paddles. Patients were treated for benign (n = 15) and malignant (n = 82) entities. All but 7 patients received donor site covering with abdominal full-thickness skin grafts. RESULTS: Of the 55 patients who received RFFFs, 5 (9.09%) developed necrosis at the end of the postsurgical period, and 7 patients developed complications of the donor site. Of the 42 patients who received VFFFs, an overall flap survival rate of 92.85% was achieved, and complications at the donor site occurred in 5 patients. For both free flaps, anesthesia time lasted from 6 to 15 hours (mean, 9.57 hours), whereas the mean flap ischemic time was 82.86 minutes. CONCLUSIONS: Our results reveal that the RFFF is a reliable method for reconstructing a wide range of oral cavity defects with an acceptably low morbidity rate. It provides adequate bulk and pliability, enabling the reconstruction of a wide variety of locations within the oral cavity. The VFFF allows good reconstruction of composite mandibular defects and provides adequate support for dental implants.

Vascularized fibular flap for reconstruction of the condyle after mandibular ablation.

PURPOSE: The purpose of this study was to evaluate the outcome of the vascularized fibular free flap for the reconstruction of mandibular resections involving the condylar segment. PATIENTS AND METHODS: Six patients underwent mandibular resection including the condyle. Two patients were diagnosed with squamous cell carcinoma, whereas the other 4 presented fibrous dysplasia, mandibular osteoradionecrosis, mandibular ameloblastoma, and giant cell granuloma of the mandible. All of them underwent condylar reconstruction by means of transplant of the free fibular flap. In all the cases, the fibula was placed directly into the glenoid fossa. The temporomandibular disc was preserved over the pole of the fibula. Panoramic radiographs were performed postoperatively to evaluate condylar position and grade of bone resorption. RESULTS: Five patients developed adequate temporofibular function with absence of hypomobility and optimum interincisal opening, whereas 1 patient developed a temporofibular ankylosis with severe limitation of mandibular mobility and mouth opening. CONCLUSIONS: The use of the fibula flap directly fitted into the glenoid fossa constitutes a reliable method in condylar reconstruction. However, the possibility of severe complications such as ankylosis has to be considered.

Unsuccessful temporomandibular joint arthroscopy: is a second arthroscopy an acceptable alternative?

PURPOSE: Arthroscopic surgery has been shown to be an effective treatment for patients with temporomandibular disorders, relieving patients' symptoms and restoring adequate mandibular function. For those patients with poor arthroscopic outcomes, various treatment modalities are possible, such as nonsurgical therapy, open surgery, or repeat arthroscopic surgery. The purpose of this study was to evaluate our results with rearthroscopy in patients with temporomandibular joint dysfunction. PATIENTS AND METHODS: The clinical data and operative reports for 50 patients who underwent a second arthroscopic procedure from 1994 to 2004 were reviewed retrospectively. Outcome assessments were based on reductions in pain, measured using a visual analog scale, and improvements in maximal interincisal opening. The minimum follow-up period was 2 years. RESULTS: Significant differences were evident between presurgical and postsurgical pain at months 1, 6, 12, and 24. The mean score of preoperative pain on the visual analogue scale was 61.65 mm, which was reduced to 36.28 mm at 2-year follow-up. With regard to mandibular function, all patients presented with restricted mouth opening, with a mean preoperative maximal interincisal opening of 26.73 mm. Postoperatively, the maximal interincisal opening showed a statistically significant improvement (P < .05), and at 2-year follow-up, we obtained a total improvement of 7 mm. Only 8 patients (16%), who had an unsuccessful result after a second arthroscopy, underwent further surgical intervention (open surgery). CONCLUSION: Arthroscopic surgery is a reliable and effective procedure for temporomandibular joint dysfunction that improves pain and mouth opening, with the advantages of being minimally invasive and repeatable. Repeat arthroscopic surgery, with a proven history of fewer complications, can be attempted before open arthrotomy.

Contralateral lymph neck node metastasis of squamous cell carcinoma of the oral cavity: a retrospective analytic study in 315 patients.

PURPOSE: In relation to primary squamous cell carcinoma (SCC) of the oral cavity, many clinical and histopathologic factors have been reported to be predictive for lymph neck node relapse. However, few large studies concerning the association between clinical-histopathologic features and the development of contralateral lymph neck node relapse (CLNR) after surgical resection of primary SCC of the oral cavity are available. The purpose of this study was to analyze those factors related to the appearance of contralateral lymph neck node relapse in patients with SCC of the oral cavity primarily treated by means of surgery. PATIENTS AND METHODS: This study was based on a series of 315 consecutive patients with primary SCC of the oral cavity treated between June 1979 and December 1999. All patients were treated primarily by means of surgery with or without adjuvant radiotherapy. The following data were analyzed for each patient: age, gender, habits, time to diagnosis, performance status, tumor clinical features, histologic grade, TNM staging, type of neck dissection, survival outcome, and functional/esthetic results at the end of the follow-up period. Histologic study included the pTNM classification, tumor size, surgical margins, extracapsular spread of lymph neck node metastasis, perineural infiltration, peritumoral inflammation, and bone involvement. RESULTS: Eighty-three patients eventually died of the disease (26.34%). A total of 177 patients were alive with no evidence of recurrence at the end of the study. The mean disease-specific survival rate was 147 +/- 6 months. Twenty-nine (9.1%) patients developed ipsilateral lymph neck node relapse (ILNR), whereas 18 (5.69%) patients developed CLNR. The mean period of time from surgery to the appearance of CLNR was 12.52 months (range, 3 to 49 months). Eighteen of 29 patients with ILNR finally died of the disease. Seven of 18 patients with CLNR died of the disease. Several clinical-pathologic features were predictive for CLNR in SCC of the oral cavity, such as the time to diagnosis, TNM staging, positive ipsilateral clinical N status, histopathologic differentiation, surgical margins of primary tumor resection, type of neck dissection, and perineural infiltration. CONCLUSION: Delay in diagnosis 12 or more months is associated with increased CLNR. Clinical and pathologic factors predictive for CLNR are TNM tumor staging IV, histopathologic poor-differentiation of the primary tumor, surgical margins less than 1 cm around the primary tumor, performance of isolated ipsilateral modified type III radical neck dissection, and perineural tumor involvement. Presence of ipsilateral neck metastasis at the time of diagnosis is associated with an augmented incidence of CLNR in SCC of the oral cavity.

Solitary cystic lymph neck node metastasis of occult thyroid papillary carcinoma.

The appearance of a solitary lateral cervical cystic mass as the only initial presenting symptom of occult thyroid carcinoma is uncommon. Its presence is often misdiagnosed due to the more frequent branchial cyst in young people. Although oronasopharyngeal squamous cell carcinoma has been reported as the main cause of lymph neck node metastasis, thyroid papillary carcinoma may be responsible for solitary cervical cystic masses as the initial manifestation of the disease. This situation has been rarely reported, although solid masses are much more frequent. In most of these cases all such lesions may initially be considered as metastatic foci from a primary thyroid lesion. However, an alternative explanation by means of which ectopic thyroid tissue is associated with a branchial cyst has to be considered, especially if no primary tumour is observed in the histological examination of the thyroid gland. We present a rare case of solitary cystic lymph node metastasis of occult papillary carcinoma of the thyroid. We also discuss possible etiology for thyroid papillary carcinoma in lateral neck cysts.

Endoscopically-assisted transoral approach for the treatment of subcondylar fractures of the mandible.

INTRODUCTION: Treatment of subcondylar fractures of the mandible is one of the most controversial aspects in the field of maxillofacial traumatology. This controversy centers on the positive and negative aspects of open and closed approaches for the treatment of this kind of fractures. Open techniques lead to good reduction and osteosynthesis, but have a high risk of injury to the facial nerve and produce facial scars. Closed techniques (intermaxillary fixation) reduce all the above-mentioned risks but rarely produce correct anatomic reduction, and complications such as ankylosis, condylar necrosis and inhibition of mandibular growth, causing abnormal occlusion, may occur. Despite all the associated risks, closed techniques are currently the most popular treatment. OBJECTIVES: To introduce the endoscopically-assisted transoral approach for the treatment of subcondylar fractures, presenting three cases treated in our department. A description of the technique has been included as well as the clinical and radiographic results obtained. MATERIAL AND METHODS: The study is based in three patients with subcondylar fractures of the mandible who were treated by an endoscopically-assisted transoral approach. A description of the surgical technique is included. The results were assessed by postsurgical radiographic control (orthopantomography), maximum mouth opening, occlusion and pain. RESULTS: Three reductions of subcondylar fractures with transoral endoscopically-assisted approach were undertaken. The follow-up period was 6 months. Postsurgical radiographic control showed good reduction of the fracture in all three cases. None of the patients showed any sign of temporomandibular dysfunction after 6 months. CONCLUSION: Endoscopic treatment by transoral approach combines the positive aspects of both conventional techniques: closed and open reduction; allowing anatomic reduction and a stable fixation leaving no visible facial scars and with a minimum risk of injury to the facial nerve.

Arthroscopic Management of Synovial Chondromatosis of the Temporomandibular Joint. Case Series and Systematic Review.

AIM: Synovial chondromatosis (SC) is a benign condition that is characterized by the formation of cartilaginous nodules within the synovial tissue of a joint that may detach and form loose bodies inside the articular space. The purpose of this study is to evaluate the use of surgical arthroscopy for the treatment of SC of the temporomandibular joint (TMJ). MATERIALS AND METHODS: A series of six patients treated with arthroscopy (one patient requiring an open arthrotomy due to the size of the loose bodies) in our centre between 1997 and 2016 is presented and results are discussed. A systematic review of the literature of patients with SC treated with arthroscopy or arthroscopy-assisted open arthrotomy is also carried out. RESULTS: Pain, which was the main symptom in our patients, and maximum mouth opening both improved significantly after surgical treatment. Three of the patients were diagnosed with primary SC, and the other 3 had a previous diagnosis of internal derangement. None of the patients showed signs of relapse during the follow-up period. CONCLUSIONS: Surgical arthroscopy is a minimally invasive procedure that allows the extraction of loose bodies and even partial synovectomy of the affected membrane with good results and without recurrence of the disease. This technique can be useful in cases of SC with loose bodies measuring less than 3 mm or without extra-articular extension.

The effect of radiation in distraction osteogenesis for reconstruction of mandibular segmental defects.

Distraction osteogenesis is useful in the reconstruction of mandibular segmental defects. The effects of radiotherapy on distracted bone after resection of squamous cell carcinoma of the oral cavity are still unknown. We report the outcome in six patients who had distraction osteogenesis after postoperative radiotherapy. Distraction was by a unidirectional semi-buried device and panoramic radiographs were taken monthly during the distraction and consolidation periods to monitor the progress of the distraction. Follow-up ranged from 15 to 45 months (mean 33). The dose of radiation ranged from 60 to 70Gy. In one patient the bone was completely exposed and all the screws were loosened. There was no calcification and the gap remained radiolucent in the panoramic radiographs. The other five patients had excellent or good quality of bone. We conclude that radiotherapy may not interfere substantially with distraction osteogenesis although larger series the necessary.

Small cell neuroendocrine carcinoma of the sinonasal region. A propose of a case.

We describe a 70-year-old man with rheumatoid arthritis and pulmonary fibrosis who presented with a month's history of pain in the left lateronasal region and inferior eyelid. On examination there was left exophthalmos, difficulty in coordinating eye movements, inflammation, erythema, and pain. Computed tomography showed a 3 cm mass in the left posterior ethmoid region, a biopsy specimen from which showed a small cell neuroendocrine tumour. He refused operation and was treated unsuccessfully with four cycles of cisplatin and etoposide.

Cavernous sinus metastasis from oropharyngeal squamous cell carcinoma.

Metastasis to the cavernous sinus from head and neck cancer is uncommon and has been previously reported by a few authors. It is usually a late manifestation of the primary tumor and may be the first evidence of a widespread dissemination of the disease. Main clinical findings are those related with involvement of cranial nerves III to VI as they pass through the cavernous sinus. Although diagnosis may be difficult, the appearance of clinical and radiological findings of cavernous sinus involvement in a context of head and neck cancer must alert us about an intracranial metastatic infiltration. In most cases treatment is palliative with radiotherapy and/or chemotherapy. The prognosis of this entity is poor, with survival of a few months. We present the case of cavernous sinus metastasis from oropharyngeal squamous cell carcinoma and review the literature about the clinical presentation and management of this rare entity.

Solitary fibrous tumour of the oral cavity with histological features of aggressiveness.

We operated on a 65-year-old woman and removed a solitary fibrous tumour from her oral mucosa. Microscopically we found marked atypia, abundant necrosis, increased number of mitotic figures (>4 in 10 high-power fields) and hypercellularity. The tumour cells were strongly stained for CD34. There has been no recurrence after 18 months.

Mandibular odontogenic myxoma. Reconstructive considerations by means of the vascularized fibular free flap.

The odontogenic myxoma is a rare entity located in mandible and upper maxilla. Due to its local aggressiveness, wide surgical excision is mandatory. Several surgical techniques have been described for the reconstruction of segmental mandibular defects. In comparison with other free flaps, the vascularized free fibular flap (VFFF) supports the longest amount of bone and, due to the nature of the vascular supply a complete freedom in location of the osteotomy is present. A precise mandibular arc can be performed following bone resection. We suggest the performance of the in situ VFFF technique in order to recreate mandibular contour by means of several osteotomies, while the pedicle is still attached to the leg. Substantial decrease in surgical time is obtained. With the double-barrel technique and subsequent osseointegrated implants, good results are obtained in the reconstruction of dentate patients without maxillary atrophy. We present two new cases of large odontogenic mandibular myxoma. Wide surgical excision by means of hemimandibulectomies and subsequent reconstruction with VFFF were performed.