Two New Surgical Techniques to Refine Surgery Around the Ear: "The Inviscision" and the External Auditory Meatus Suture.

Numerous incisions around the ear have been described, and many have been used in oral and maxillofacial surgery for procedures involving the temporomandibular joint (TMJ), condylar neck, and parotid gland, as well as for rhytidectomy.1-5 Although the traditional preauricular and endaural incisions will frequently provide an excellent outcome, they will heal with a visible scar.1,4 The incision we have described aims to refine the incision to further improve this esthetic outcome. Additionally, surgical procedures around the ear have often resulted in the unpleasant and inconvenient collection of blood or surgical skin preparation in the ear canal. Although not recorded in reported studies, in our experience, patients have commonly complained of "blocked ears" for 1 to 2 weeks in the postoperative period. Although this complication represents minimal risk, it can often be difficult, once clotted or dried, to remove and will be bothersome to the patient. In addition, any packing placed in the external auditory canal (EAC) intraoperatively to mitigate the collection of blood will often and repeatedly dislodge from the EAC, requiring replacement multiple times during the procedure to the frustration of the surgeon. The techniques we have described are 2 straightforward, but innovative, surgical techniques that refine surgery around the ear to improve the esthetics and patient comfort, facilitate the surgical procedure, and increase reliable anatomic access. The modified incision we have described is predominately aimed at operations requiring access to the TMJ, condylar neck, or parotid gland. The techniques were, to the best of our knowledge, first used in our unit at the University of Maryland.

Takotsubo Syndrome After Surgical and Nonsurgical Oral and Maxillofacial Events: Review of Published Cases.

PURPOSE: Takotsubo syndrome (TS) is an acute and potentially serious cardiac disorder that is often attributed to an exuberant catecholaminergic response to a severely physical or emotional event. As there is a paucity of information in the dental literature on TS, this article will provide an overview of this uncommon syndrome, including clinical presentation, demographic characteristics, etiopathogenesis, diagnosis, management, and recovery, particularly emphasizing its occurrence with oral and maxillofacial procedures. PATIENTS AND METHODS: A PubMed search with the keyword "takotsubo" for publications from 1991 through May 2018 yielded 3,778 articles. Case reports and case series of TS associated with surgical and nonsurgical procedures in the oral and maxillofacial region were reviewed. Other cases were identified using a defined search strategy. RESULTS: The literature search identified 28 documented episodes of TS that occurred with head and neck surgical procedures, mostly sinus, carotid, nasal, and cancer reconstruction surgical procedures, and notably, 3 cases occurred concurrently with dental extractions. In all of the featured patients, some degree of cardiovascular impairment developed and phenotypic overlap with acute occlusive coronary disease was shown. Most patients recovered within 2 weeks, and recovery in the remainder extended up to 3 months. CONCLUSIONS: On rare occasions, TS has been reported in association with oral and maxillofacial procedures. As stress appears to be a precipitating factor in the development of TS, perioperative efforts should be instituted to reduce an adrenergic cascade.

Cone-beam computed tomography education and exposure in oral and maxillofacial surgery training programs in the United States.

PURPOSE: The purpose of this study was to estimate the penetration of cone-beam computed tomography (CBCT) in oral and maxillofacial surgery (OMS) residency programs in the United States. In addition, this study was designed to assess the education and training, relevance, and image interpretation responsibility of CBCT as experienced by OMS residents. MATERIALS AND METHODS: The authors performed a cross-sectional study of all 102 US-based OMS program directors (PDs) from January 1, 2014 through April 30, 2014. Study variables included questions about 4 key factors in CBCT in OMS programs: access, education and training, relevance, and image interpretation responsibility. Data analysis was a product of the percentage of positive responses to each question. RESULTS: Fifty-four PDs participated in the study. The results showed that 87% of responding OMS programs have access to CBCT and that CBCT is used primarily for dental implant-related procedures. CONCLUSION: OMS residents are actively involved in CBCT use in their residency. OMS residents' access to CBCT is increasing, and their education, training, and image interpretation responsibility is increasing.

Reconstruction of the mandibular condyle due to degenerative disease.

Degenerative joint disease (DJD), also known as osteoarthritis is the most common form of arthritis and can affect the temporomandibular joint (TMJ). TMJ DJD is characterized by degradation of the articular cartilage and synovial tissues resulting in characteristic morphologic changes in the underlying bone. DJD can occur at any age, but it is more common in older age groups. TMJ DJD may be unilateral or bilateral. The American Academy of Orofacial Pain categorizes TMJ DJD into primary and secondary types. Primary DJD is seen in the absence of any local or systemic factors and secondary DJD is associated with a prior traumatic event or disease process. Frequently, these patients present with pain and limited residual mandibular function resulting in significantly diminished quality of life. Classic radiographic features on orthopantogram and CT imaging include loss of joint space, osteophytes (bird-beak appearance of the condyle), subchondral cysts, erosions, flattening of the condylar head, bony resorption and/or heterotopic bone (Figure 1). Conservative and medical management is successful in the majority of patients until the active degenerative phase burns out, but some will progress to end stage joint disease and require reconstruction of the TMJ. Reconstruction of the mandibular condyle should be considered to restore mandibular function and form to patients who have lost it secondary to degenerative joint disease affecting the glenoid fossa/mandibular condyle unit.

RE: Biomechanical comparative analysis of temporomandibular joint, glenoid fossa and head of the condyle of conventional models prothesis with new PEEK design.

This is a Letter to the Editor that describes some of the biomechanical concerns with the statements made in This is a LTE that raises some biomechanical statements made in Genovesi W, Comenale IC, Genovesi Filho W, Veloso Fernandes M. Biomechanical comparative analysis of temporomandibular joint, glenoid fossa and head of the condyle of conventional models prothesis with new PEEK design. J Oral Biol Craniofac Res. 2022 Sep-Oct; 12(5):529-541.

Extracorporealization of the Mandibular Condyle: Effects on Viability and Function.

Study Design: For certain condylar fractures, extracorporealization of the condylar segment may be performed via extra-oral vertical ramus osteotomy (EVRO) to facilitate reduction and fixation. This approach can similarly be used for condyle-sparing resection of osteochondromas of the condyle. Due to controversy regarding long-term health of the condyle after extracorporealization, we conducted a retrospective analysis of surgical outcomes. Objective: For certain condylar fractures, extracorporealization of the condylar segment may be performed via extra-oral vertical ramus osteotomy (EVRO) to facilitate reduction and fixation. This approach can similarly be used for condyle-sparing resection of osteochondromas of the condyle. Due to controversy regarding long-term health of the condyle after extracorporealization, we investigated the viability of this technique through a retrospective analysis of outcomes. Methods: Twenty-six patients were treated using EVRO with extracorporealization of the condyle for both condylar fractures (18 patients) and osteochondroma (8 patients). Of the 18 trauma patients, 4 were excluded due to limited follow-up. Clinical outcomes were measured, including occlusion, maximum interincisal opening (MIO), facial asymmetry, incidence of infection, and temporomandibular joint (TMJ) pain. Radiographic signs of condylar resorption were investigated, quantified, and categorized using panoramic imaging. Results: Average follow-up was 15.9 months. Average maximum interincisal opening was 36.8 mm. Four patients demonstrated mild resorption and one patient demonstrated moderate resorption. Two cases of malocclusion were attributed to failed repairs of other concurrent facial fractures. Three patients reported TMJ pain. Conclusions: Extracorporealization of the condylar segment with EVRO to facilitate open treatment of condylar fractures is a viable treatment option when more conventional approaches prove unsuccessful.

Secretory leukocyte protease inhibitor (SLPI) expression and tumor invasion in oral squamous cell carcinoma.

Differential expression of secretory leukocyte protease inhibitor (SLPI) impacts on tumor progression. SLPI directly inhibits elastase and other serine proteases, and regulates matrix metalloproteinases, plasminogen activation, and plasmin downstream targets to influence invasion. We examined tissues from human oral squamous cell carcinoma (OSCC) for SLPI expression in parallel with proteases associated with tumor progression and evaluated their relationships using tumor cell lines. Significantly decreased SLPI was detected in OSCC compared to normal oral epithelium. Furthermore, an inverse correlation between SLPI and histological parameters associated with tumor progression, including stage of invasion, pattern of invasion, invasive cell grade, and composite histological tumor score was evident. Conversely, elevated plasmin and elastase were positively correlated with histological parameters of tumor invasion. In addition to its known inhibition of elastase, we identify SLPI as a novel inhibitor of plasminogen activation through its interaction with annexin A2 with concomitant reduced plasmin generation by macrophages and OSCC cell lines. In an in vitro assay measuring invasive activity, SLPI blocked protease-dependent tumor cell migration. Our data suggest that SLPI may possess antitumorigenic activity by virtue of its ability to interfere with multiple requisite proteolytic steps underlying tumor cell invasion and may provide insight into potential stratification of oral cancer according to risk of occult metastasis, guiding treatment strategies.

Current Treatment Strategies for the Management of the Internal Derangements of the Temporomandibular Joint: A Global Perspective.

Internal joint derangement is a disruption of the internal aspects of the TMJ-disc displacements/adhesions/impingements, causing alterations in the normal dynamic motions of the joint. Clinicians must be diligent in establishing the correct diagnosis and cause of TMJID, which ultimately leads to the appropriate management of such patients. While many patients adapt over time or with non-surgical treatment, surgery may be indicated for those with ongoing problems. The surgical pyramid provides a stepwise progression for TMJ surgical patients. This paper aims to review TMJID and its management with special emphasis on arthroscopic minimally invasive surgery, as practised in other countries around the world, and compare this to current education, understanding and practice in India. Currently, India is lagging behind in providing the full scope of TMJ services as there are very few surgeons trained in the skill of arthroscopic techniques. There needs to be continued expansion of our understanding of TMJID treatment in India to bring it level with the rest of the world.

Juvenile trabecular ossifying fibroma: Immunohistochemical expression of MDM2, CDK4 and p53 compared to conventional ossifying fibroma.

BACKGROUND: Juvenile ossifying fibroma (JOF) is an uncommon benign fibro-osseous lesion of the craniofacial skeleton; compared to conventional ossifying fibroma (OF), JOF is characterized by local aggressiveness and propensity for recurrence. The biologic basis for this different biologic behavior between JOF and OF remains elusive. The aim of this study was to evaluate the immunohistochemical expression of MDM2, CDK4 and p53, molecules associated with bone oncogenesis, in the trabecular variant of JOF. MATERIAL AND METHODS: The study material consisted of five cases of trabecular JOF, affecting three male and two female patients with a mean age of 11.8 years. Three cases arose in the maxilla and two in the mandible. All cases were initially treated by enucleation; two cases recurred necessitating more aggressive treatment. Immunohistochemical study of MDM2, CDK4 and p53 was performed in all cases, as well as in five control cases of conventional OF. RESULTS: CDK4 positivity was noted in all JOF cases; the staining pattern was diffuse and strong in 4 cases and focal and weak in one case. In contrast, 4 out of 5 cases of OF were weakly and focally CDK4 positive, the remaining one being negative. Immunostaining for MDM2 was observed in 3 JOF cases; all OF were MDM2 negative. All cases of OF and JOF were negative for p53, except for one focally positive JOF case. CONCLUSIONS: CDK4 and MDM2 expression in the trabecular variant of JOF is higher compared to conventional OF. In contrast, p53 expression is almost universally negative in JOF and OF. Despite some overlapping features, differential expression patterns of proteins involved in bone oncogenesis can elucidate the pathogenesis and may facilitate accurate diagnosis and prediction of behavior of bone tumors in the craniofacial region. Key words:Juvenile ossifying fibroma, trabecular variant, conventional ossifying fibroma, MDM2, CDK4, p53.

The Opioid Analgesic Reduction Study (OARS)-a comparison of opioid vs. non-opioid combination analgesics for management of post-surgical pain: a double-blind randomized clinical trial.

BACKGROUND: Everyday people die unnecessarily from opioid overdose-related addiction. Dentists are among the leading prescribers of opioid analgesics. Opioid-seeking behaviors have been linked to receipt of initial opioid prescriptions following the common dental procedure of third molar extraction. With each opioid prescription, a patient's risk for opioid misuse or abuse increases. With an estimated 56 million tablets of 5 mg hydrocodone annually prescribed after third molar extractions in the USA, 3.5 million young adults may be unnecessarily exposed to opioids by dentists who are inadvertently increasing their patient's risk for addiction. METHODS: A double-blind, stratified randomized, multi-center clinical trial has been designed to evaluate whether a combination of over-the-counter non-opioid-containing analgesics is not inferior to the most prescribed opioid analgesic. The impacted 3rd molar extraction model is being used due to the predictable severity of the post-operative pain and generalizability of results. Within each site/clinic and gender type (male/female), patients are randomized to receive either OPIOID (hydrocodone/acetaminophen 5/300 mg) or NON-OPIOID (ibuprofen/acetaminophen 400/500 mg). Outcome data include pain levels, adverse events, overall patient satisfaction, ability to sleep, and ability to perform daily functions. To develop clinical guidelines and a clinical decision-making tool, pain management, extraction difficulty, and the number of tablets taken are being collected, enabling an experimental decision-making tool to be developed. DISCUSSION: The proposed methods address the shortcomings of other analgesic studies. Although prior studies have tested short-term effects of single doses of pain medications, patients and their dentists are interested in managing pain for the entire post-operative period, not just the first 12 h. After surgery, patients expect to be able to perform normal daily functions without feeling nauseous or dizzy and they desire a restful sleep at night. Parents of young people are concerned with the risks of opioid use and misuse, related either to treatments received or to subsequent use of leftover pills. Upon successful completion of this clinical trial, dentists, patients, and their families will be better able to make informed decisions regarding post-operative pain management. TRIAL REGISTRATION: ClinicalTrials.gov NCT04452344 . Registered on June 20, 2020.

A randomized prospective comparison of maxillomandibular fixation (MMF) techniques: "SMARTLock" hybrid MMF versus MMF screws.

OBJECTIVE: The aim of this study was to assess the efficacy of the "SMARTLock" hybrid system and determine whether it results in fewer intraoperative and postoperative complications compared with placement of intermaxillary fixation (IMF) screws in trauma patients. STUDY DESIGN: This prospective study, which was approved by the institutional review board, compared the results of MMF in mandibular fractures by using the Stryker "SMARTLock" hybrid system versus traditional IMF screws. Patients were recruited and assigned randomly to either group. The 2 groups were compared for placement time, intraoperative complications, loosening of hardware, postoperative complications, and time to device removal. RESULTS: We enrolled 32 patients in the study, with 13 patients randomized to the group receiving hybrid MMF (HMMF) with the SMARTLock system and 19 to the group of patients receiving MMF with traditional IMF screws. The mean application time for HMMF was 25.92 minutes compared with 18.28 minutes for IMF screws. After removal, the HMMF was associated with gingival overgrowth and gingival edema. CONCLUSIONS: This is the first study to compare HMMF with MMF with the use of IMF screws. Hybrid arch bars do require more manipulation for ideal placement compared with individually placed bone screws to achieve ideal MMF. Compared with IMF screws, the hybrid device was associated with gingival edema and overgrowth, but there was decreased incidence of loosening in the postoperative period.

Computer-Assisted Planning and Intraoperative Navigation in the Management of Temporomandibular Joint Ankyloses.

Temporomandibular joint ankyloses are a fusion of the mandibular condyle to the base of skull. Surgical advances have stemmed from innovation in computer planning, guidance, and intraoperative navigation, allowing surgeons to restore form and function with greater precision, predictability, and safety. Preoperative computer virtual surgical planning used the computed tomography scan data to render a 3-dimensional image that can be used for surgical simulations and fabrication of intraoperative aids. Temporomandibular joint reconstruction should be considered as a predictable option in the management of temporomandibular joint ankylosis. Intraoperative navigation allows for continuous real-time 3-dimensional positioning of instruments.

A novel bioassay model to determine clinically significant bisphosphonate levels.

PURPOSE: Bisphosphonate-associated osteonecrosis (BON) is a recently recognized oral complication of bisphosphonate (BP) therapy. Currently, research into the pathogenesis of BON has been hampered by being deficient in studies capable of measuring the level of BP in saliva or at the bone-soft tissue interface. The objective of this current study was to develop a novel bioassay model representative of the oral levels of BPs in patients presenting with or at risk for BON. METHODS: Zoledronic acid (ZA) injectable was used to develop standardized MTS cell proliferation assay curves at concentrations of 0-10 microM, which were used either in a dilution in normal media, mimicking BP freed from bone or used to "spike" saliva individuals not taking BPs and mimicking BP levels being excreted. This bioassay was then used to estimate BP levels from samples of saliva and bone ex vivo from patients with and without BON. RESULTS: Saliva and bone from patients with existing BON showed levels of BP ranging from 0.4 to 4.6 microM, while patients receiving IV infusion of BP and naïve to BON showed levels in saliva ranging from 0.4 to 5 microM. All control specimens and patients naïve to BP showed levels at 0 microM. CONCLUSIONS: Given the fact that BPs are poor candidates for detection using standard methods (HPLC), this bioassay provides us with the ability to estimate clinically relevant concentrations of BP capable of producing apoptosis and the inhibition cell proliferation of oral mucosal cells based on previous studies. Subsequently, apoptosis and the inhibition of proliferation could lead to BON, secondary to the exposure of the bone in the unique microenvironment of the oral cavity.

Up-regulation of SIBLING proteins and correlation with cognate MMP expression in oral cancer.

Various combinations of the SIBLING family of proteins have been found to be up-regulated in many human cancers and have been linked to different stages of tumor progression, including metastasis. Bone sialoprotein (BSP), osteopontin (OPN) and dentin matrix protein 1 (DMP1) specifically bind and activate MMP-2, MMP-3, and MMP-9, respectively. These proteases have also been shown to play important roles in oral squamous cell carcinoma (OSCC) invasion and metastasis. However, with the exception of OPN, there are no reports on the expression of the family of five SIBLING proteins in OSCC. This study examines the expression patterns of the SIBLING family (and MMP partners when known) in OSCC, correlating expression to outcome variables. Archived paraffin sections of 87 cases of primary OSCC were screened by immunohistochemistry for the SIBLINGs and their MMP partners. Three SIBLINGs (BSP, DSPP, and OPN), were expressed in OSCC, while DMP1 and MEPE expression were never observed. Furthermore, BSP and OPN were always expressed with their known MMP partners, MMP-2 and MMP-3, respectively. Poorly differentiated tumors exhibited reduced or no immunoreactivity for BSP and OPN but increased immunoreactivity for DSPP. Seventy eight (90%) cases were positive for BSP and DSPP, while 79 cases (91%) were positive for OPN. Overall, 91% of the cases were positive for at least one SIBLING. There were no correlations between SIBLING expression and tumor size ("T"; of the Union Internationale Contre le Cancer [UICC]-TNM classification for OSCC), and between SIBLING expression and lymph node spread for the T1/T2 tumors. The levels of DSPP expression for floor of mouth and retromolar region tumors were higher than for tongue tumors. Statistically significant correlations were, however, found between the expression levels of BSP and MMP-2 (p<0.0001), BSP and MMP-3 (p<0.0001), and OPN and MMP-3 (p<0.0024). We conclude that BSP, DSPP, and OPN are highly up-regulated in OSCC. While the production of these SIBLINGs is independent of T, they correlate with oral location of tumor, cognate MMP expression, and for DSPP, the degree of tumor differentiation.

Valvular heart disease and heart failure: dental management considerations.

Approximately 5 million people are diagnosed with valvular heart disease in the United States each year. Many of these will present to the general dentist for routine dental care. The dentist must then understand the implications of this disease process to treat these patients safely and effectively. Of course patients with pathologic valve disease are managed in close consultation with their physicians. Even so, a dentist with knowledge of the disease process, as well as its diagnosis and treatment, has greater confidence when treating these patients. This article summarizes issues related to valvular heart disease and heart failure and provides guidance to dentists treating patients with such conditions.

Keratocystic Odontogenic Tumor (KCOT/OKC)-Clinical Guidelines for Resection.

PURPOSE: There is no clinical consensus for the treatment of Keratocystic Odontogenic Tumor (KCOT). KCOTs are regarded as benign aggressive tumors and resection is usually considered as a last option. We review the clinical indications for resection based on a case series. METHODS: This is a retrospective study of patients with KCOT treated in a single unit over 17 years. Eighty patients were identified, of which 12 (15 %) underwent resection. The remaining 68 patients were managed by enucleation and curettage, enucleation with peripheral ostectomy, or decompression with secondary enucleation. Data extracted includes gender, age, race, location, previous treatment for the lesion, surgery and outcome/follow up. RESULTS: Twelve patients treated by resection were identified. The location in the ten benign resected KCOTs was either the mandibular ramus or the posterior maxilla. All mandibular KCOTs exhibited perforation of the lingual plate and involvement of the pterygoid musculature. Seven of the ten cases were recurrent KCOTs and three had no prior treatment. Two had malignant changes in the KCOT and were also resected. CONCLUSION: The primary reason for resection of KCOT was involvement of the pterygoid muscles. The presence of malignant change was a separate indication for resection.

Histopathological and lymphangiogenic parameters in relation to lymph node metastasis in early stage oral squamous cell carcinoma.

PURPOSE: Lymph node metastasis from oral squamous cell carcinoma (SCC) correlates with a poor prognosis. Therefore, accurate assessment of lymph node status is crucial in treatment planning. Furthermore, prediction of delayed neck metastasis (DNM), especially in early stage tumors with a clinically negative (N0) neck, will determine the need for neck dissection or irradiation. In this study, we assess various clinical, histopathological and lymphangiogenic parameters in early stage oral SCC and their association with DNM. MATERIALS AND METHODS: Clinical, histological, and immunohistochemical analyses were undertaken for 29 patients with T1N0M0 or T2N0M0 oral SCC affecting the tongue or floor of mouth and correlated with the development of DNM. RESULTS: Tumor thickness, nuclear pleomorphism, pattern of invasion, and immunohistochemical expression of the lymphangiogenesis-associated molecules VEGFR-3 and VEGF-C were associated with DNM. CONCLUSIONS: Analysis of these parameters may help to identify patients who would benefit from a neck dissection or irradiation by predicting the likelihood of lymph node metastasis.

Transcriptional events in a clinical model of oral mucosal tissue injury and repair.

Tissue injury in the oral mucosa activates a cascade of transcriptional events important during the healing process that are not yet clearly defined. To characterize these events and identify potential gene targets for future studies, we used cDNA expression arrays in a clinical model of tissue injury. Mucosal biopsies were taken before third molar extraction, 2-4 hours postoperatively, or at 48 hours. Hybridization patterns were analyzed and validated using real-time polymerase chain reaction. Prior to extraction, the biopsied mucosal tissues were characterized by a panoply of genes that were constitutively expressed. After injury, analysis revealed differential expression of genes involved in transcription, inflammation, and remodeling. At 2-4 hours after injury, genes such as Fos, Jun, and early growth response protein were up-regulated, while genes responsible for intercellular adhesion were down-regulated. At 48 hours after injury, the gene profile had shifted toward tissue remodeling. Here we identify genes constitutively expressed in normal oral mucosa and transcriptional events following mucosal tissue injury, which may be useful in identifying new therapeutic targets.