Patient motivation and satisfaction from orthognathic surgery-a case series.

OBJECTIVE: This study attempted to understand the specific motivations of patients who undergo orthognathic surgery and determine their satisfaction with the surgery. The study also assessed the prevalence of complications and how they may impact patient satisfaction. STUDY DESIGN: Patients who underwent orthognathic surgery at the University of California between 2016 and 2019 and had completed postoperative orthodontic treatment for ≥9 months were interviewed. They responded to an open-ended telephone interview regarding their motivations, satisfaction, and complications. RESULTS: The patients showed a high level of satisfaction with the surgery, but there were persistent complications that affected satisfaction. The predominant complication was paresthesia over the distribution of the inferior alveolar nerve. The majority of patients who reported prior headaches and temporomandibular joint problems described improvement in those areas. Comparing the patients' motivations before and after surgery showed that before surgery, patients reported functional concerns, whereas postoperatively they were much more likely to recall aesthetic reasons for the surgery. CONCLUSION: This study showed that although patients are generally satisfied after orthognathic surgery, patients need to be realistically informed of their expectations and adequately informed of possible complications.

Denosumab for the management of central giant cell granuloma of the jaws-a case series.

Denosumab has been suggested as a medical treatment for central giant cell granuloma of the jaws. This study included eight patients, seven female and one male, aged between 19 and 32 years, with biopsy-proven central giant cell granuloma of the mandible. The patients were treated with subcutaneous injections of 120 mg of denosumab in a regime consisting of three injections at weekly intervals followed by five injections at monthly intervals over a 6-month period. They were followed up for between 60 and 71 months clinically and radiographically with panoramic radiographs and cone beam computed tomography scans. All of the lesions became calcified radiographically and asymptomatic clinically. They did not reduce in size, but to date only one patient has requested surgical remodeling. There has been no recurrence or regrowth in over 5 years.

Previously successful dental implants can fail when patients commence anti-resorptive therapy-a case series.

This article reports a type of localized osteonecrosis that can occur in patients who have had successful osseointegrated implants for many years and then commence anti-resorptive therapy. Eleven female patients were identified who had successful implant insertion, but who were placed on anti-resorptive therapy (bisphosphonates or denosumab) several years later and developed osteonecrosis around the implants. In each case, the osteonecrosis occurred only around the implants and not around the patient's remaining teeth. The implants of eight patients were removed with a sequestrum of bone tightly adherent to the implant. This is different from the normal pattern of implant failure. Implant failure can occur when patients with successfully integrated implants are later placed on anti-resorptive therapy, and the osteonecrosis takes a particular form where a sequestrum forms that remains adherent to the implant. Why the adjacent remaining teeth are not affected is unclear.

Desmoplastic fibroma of the mandible in young children-a case series.

Desmoplastic fibromas are rare, benign, but aggressive lesions, affecting predominantly young people, with an affinity for the mandible. Four patients with desmoplastic fibromas of the mandible, seen between 1995 and 2015 with long-term follow-up, were identified. Three were treated by wide mandibular resection and immediate reconstruction with rib grafts, and one was treated with chemotherapy. In the three resected cases, there has been no recurrence and all rib grafts were successfully incorporated. The case treated by chemotherapy has persistence of the tumour, but it is not progressing. Desmoplastic fibromas in young children respond well to wide mandibular resection and immediate reconstruction with rib grafts. Chemotherapy may halt progression.

The keratocystic odontogenic tumour (KCOT)--an odyssey.

The most appropriate management for the lesion now known as the keratocystic odontogenic tumour (previously known as the odontogenic keratocyst) remains controversial. This article reviews the different management protocols adopted by one surgical unit over the last 30 years and the results obtained from the different treatment modalities. A current treatment protocol consisting of initial decompression followed by aggressive curettage and peripheral ostectomy with methylene blue staining appears to be successful, but our longest follow-up is only 6 years.

The keratocystic odontogenic tumor.

In 2005, the World Health Organization renamed the lesion previously known as an odontogenic keratocyst as the keratocystic odontogenic tumor. The clinical features associated with the keratocystic odontogenic tumor show it to be a unilocular or multilocular radiolucency, occurring most frequently in the posterior mandible. These tumors are normally diagnosed histologically from a sample of the lining. With simple enucleation, it seems that the recurrence rate may be from 25% to 60%.

Orthognathic surgery for the Asian patient and the influence of the surgeon's background on treatment.

The aim of this study was to determine whether there are differences in esthetic preferences and orthognathic treatment for Asian patients between US- and Asian-trained surgeons. Twenty-five Caucasian-American, 23 Asian-American, 24 Asian oral and maxillofacial surgeons (OMFS) completed an Institutional Review Board (IRB)-approved survey. They were asked to rate seven Asian male and female profiles from most attractive to least attractive and to choose maxillary advancement, mandibular setback, or no treatment for an Asian male and female patient with a maxillomandibular discrepancy. There was no statistical difference for the most and least attractive rankings among the OMFS. Variations in ranking for intermediate profiles showed a statistical difference between the Asian- and US-trained OMFS. These intermediate profile rankings appeared to explain the differences in surgical treatment. Treatment recommendations for the Asian male among the OMFS, regardless of ethnicity, preferred maxillary advancement. For the Asian female, all Asian-trained OMFS preferred mandibular setback, while nearly 40% of US-trained OMFS preferred maxillary advancement (p=0.003). Differences in surgical management of the Asian patient were dependent on whether the surgeon trained in the US or in Asia and the gender of the patient. There was concordance between the Asian-American and Caucasian-American surgeons.

Is there a role for enucleation in the management of ameloblastoma?

This study aimed to determine the appropriate long-term management for ameloblastoma and the role of enucleation in the management of the subtypes of ameloblastoma (solid ameloblastomas, cystic ameloblastomas and peripheral ameloblastomas). They differ in their degrees of aggressive behavior and recurrence rates. This is an evidence-based study with review of relevant articles from PubMed, EMBASE and the Cochrane Library. Articles were categorized for quality according to the Oxford Center of Evidence-Based Medicine (CEBM). 58 articles met the inclusion criteria; their evidence level varied from IIA to V. No randomized control trials were identified. Solid and multicystic ameloblastomas have a high recurrence rate (60-80%) with simple enucleation and require more aggressive treatment. The treatment of choice is resection with 1-cm margins. This may require segmental resection in the mandible, and partial maxillectomy in the maxilla. For the unicystic ameloblastoma recurrence rates are high for simple enucleation. The intraluminal subtype of unicystic ameloblastoma may do well with enucleation, but the intramural subtype may not, and since these cannot be identified preoperatively more aggressive treatment is recommended, including peripheral ostectomy or enucleation with subsequent treatment of the surrounding bone with liquid nitrogen, Carnoy's solution, or similar physicochemical modality. The peripheral ameloblastoma has a different origin and responds to local excision.

A five-year retrospective study of odontogenic maxillofacial infections in a large urban public hospital.

The aim of this study was to analyze the etiology, presentation, management and outcome of odontogenic maxillofacial infections seen in an urban population that has only one major public hospital, which is also the only level I trauma center. All patients admitted to the Oral and Maxillofacial Surgery Service of San Francisco General Hospital with odontogenic infections over a 5-year period were included. Age, gender, site of infection, investigations performed, treatment carried out and outcomes were studied. Length of hospital stay and any readmissions were also noted. A total of 250 patients were admitted with maxillofacial infections, and in 157 cases the infection was odontogenic in origin. Males outnumbered females (102:55). Children had a preponderance of maxillary buccal infections whilst adults had more mandibular infections. Hospital stays ranged from 1 to 23 days, and only one patient required re-admission. A wide range of antibiotics were prescribed and 122 patients required dental extractions. Odontogenic maxillofacial infections are a public and personal health issue with potential life-threatening complications. This study identifies potential risk factors and suggests that early dental extraction, incision and drainage, coupled with intravenous antibiotic therapy, is the most effective treatment. Antibiotic therapy can be empirical since in no case where cultures were performed did this alter the antibiotic management.

Neurosensory changes after liquid nitrogen cryotherapy.

PURPOSE: The study goal was to evaluate neurosensory changes after liquid nitrogen cryotherapy in the management of mandibular lesions in close proximity to the inferior alveolar nerve. PATIENTS AND METHODS: The design of the study was a retrospective review. Sixteen patients with posterior mandibular lesions (15 odontogenic keratocysts and 1 fibromyxoma) in close proximity to the inferior alveolar nerve were treated with a standardized enucleation and cryotherapy technique. Postoperative evaluation included patients report of symptoms and formal neurosensory testing. RESULTS: All patients had altered sensation in the distribution of the inferior alveolar nerve immediately after cryotherapy. Two patients experienced anesthesia, and the remaining 14 patients showed paresthesia. The average time for return or improvement in sensation was 91 days (range, 6 to 235 days). The average time of follow-up was 2.6 years (range, 0.5 to 7.3 years). At the time of last follow-up, no patients had anesthesia or dysesthesia. Four patients had full return of sensation and 12 patients had paresthesia. No patients reported significant difficulty from abnormal nerve function. All 16 patients experienced some return of sensation; 9 patients had full or near full return of sensation. CONCLUSIONS: Based on these results, the combination of enucleation and liquid nitrogen cryotherapy produces minimal alteration of inferior alveolar nerve function.

Reconstruction of extensive maxillary defects using zygomaticus implants.

PURPOSE: Maxillary reconstruction after maxillectomy remains a great challenge for the reconstructive oral and maxillofacial surgeon. This article is a clinical retrospective analysis of patients reconstructed with zygomaticus implants after maxillary ablation. PATIENTS AND METHODS: The design of the study was a retrospective review of 9 patients requiring near-total or total maxillectomy for pathologic reasons. Clinical records, photographs, and radiographs were studied. Financial billing statements were reviewed to determine charges for implant reconstruction and method of payment. RESULTS: Maxillary reconstruction using zygomaticus and standard endosseous implants was performed in 9 patients. Maxillary resection was performed for the following reasons: salivary gland malignancy (n = 2), squamous cell carcinoma (n = 5), maxillary mucormycosis (n = 1), and extensive maxillary atrophy and infection secondary to subperiosteal maxillary implant placement (n = 1). A total of 28 zygomaticus implants and 10 standard endosseous implants were used to reconstruct the 9 patients. Six zygomaticus implants and 3 standard endosseous implants failed. The time of zygomaticus implant placement ranged from placement at the time of resection to 3.2 years after the resection. Five patients received radiation therapy. Five patients have been reconstructed with a maxillary obturator and have been functioning with the prosthesis for a minimum of 2 years. CONCLUSION: The combination of zygomaticus and standard endosseous implants can be used to reliably reconstruct patients after extensive resection of the maxilla.

Calcitonin therapy for central giant cell granuloma.

PURPOSE: A number of alternative nonsurgical therapies have been advocated in recent years for the management of the central giant cell granuloma (CGCG). These include calcitonin injections, intralesional steroid injections and subcutaneous alpha-interferon injections. This report provides the results of calcitonin therapy. MATERIALS AND METHODS: Ten patients received calcitonin therapy, 9 via subcutaneous injection and 1 via nasal spray, for the management of a CGCG. Patients were reviewed retrospectively RESULTS: In 8 cases, the lesions resolved completely after 19 to 21 months of subcutaneous calcitonin treatment. In the ninth case, the lesion resolved on calcitonin treatment only to reappear 26 months later. The recurrence was treated with both repeated calcitonin and local enucleation. The tenth case with calcitonin (intranasal) treatment was abandoned due to poor patient compliance, and the patient ultimately underwent surgical treatment. CONCLUSION: Calcitonin treatment appears to be a viable option for the treatment of CGCGs but, because of the length of treatment time, should probably be reserved for multiple lesions, recurrent lesions, or particularly aggressive lesions. The exact mechanism of action of both calcitonin and other treatment modalities remains to be fully elucidated. The reported success of all such treatments raises questions about the natural history of this lesion.

Effects of liquid nitrogen cryotherapy and bone grafting on artificial bone defects in minipigs: a preliminary study.

Liquid nitrogen cryotherapy has been advocated as an adjunct in the enucleation and curettage of locally aggressive lesions of the jaws. Simultaneous autogenous bone grafting has also been advocated to accelerate bone formation and reduce morbidity. There is, however, relatively little scientific basis for either of these hypotheses. In this study, nine Yucatan minipigs had artificial defects created in the mandible, which were treated with liquid nitrogen spray. Half of the defects were grafted with autogenous bone from the chin and half were closed primarily. Two animals were sacrificed 3 days postoperatively to measure the width of necrosis and the rest were sacrificed at 3 months to assess healing and new bone formation. It was found that drilling the artificial defects alone caused bone necrosis for a mean depth of 0.09 mm. Liquid nitrogen cryospray caused a mean depth of bone necrosis of 0.82 mm (range 0.51-1.52 mm). The defects that were bone grafted healed well clinically. Defects not bone grafted showed a 50% rate of wound breakdown and sequestrum formation with delayed healing. Vital staining showed a non-significantly greater rate of bone formation in the grafted defects. Digitally superimposed radiography showed a non-significantly greater bone density in the non-grafted defects at 3 months postoperatively. It appears that liquid nitrogen cryospray does devitalize an area of bone around defects in the mandible. The width of necrosis is usually less than 1 mm and subsequent healing is enhanced by autogenous bone grafting. This has clinical implications.

Cystic ameloblastoma--behavior and treatment of 21 cases.

PURPOSE: This article presents a series of cystic ameloblastomas in which an unexpected capacity for bony destruction and recurrence was shown. Proliferation rates were evaluated to see if there is a correlation to the biologic behavior of these lesions. MATERIALS AND METHODS: Clinical and histologic material on 21 consecutive cystic ameloblastomas was retrieved and reviewed. Immunohistochemical analysis of proliferation-associated Ki-67 protein was carried out to determine mitotic indices for 10 cystic ameloblastomas, and these were compared to 10 solid ameloblastomas and 10. dentigerous cysts. RESULTS: Lesions from 10 males and 11 females (age range, 12 to 72 years; mean age, 35 years) were included. All lesions were in the mandible; 18 in posterior sites. Lesion size ranged from 2 to 8 cm in greatest dimension. Cortical perforation was evident in 7 lesions, and multilocularity (more often in older patients) was evident in 6 lesions. Recurrences were seen in 9 cases (43%), and the time between initial treatment and recurrence was as long as 10 years. The characteristic histopathologic feature was a thin, stratified squamous cystic lining with spongiosis and basal palisades. Ten cases also showed mural invasion, and 4 had plexiform luminal proliferation. The proliferation rate of the cystic ameloblastomas (represented as a percentage of cells in cell cycle) was 4.3%, compared with solid tumors at 2.8% and dentigerous cysts at 6.6%. CONCLUSIONS: Cystic ameloblastomas occur within a wide age range, but at slightly lower mean age than solid lesions. There is a very strong predilection for the mandible, and there appears to be no gender difference. Lesions frequently become large, destructive, and/or multilocular. There is a significant recurrence potential, and extended follow-up is advisable. The deceptively innocent histology of cystic ameloblastomas belies the biologic potential of these lesions. The mechanism(s) by which cystic ameloblastomas gain their destructive behavior seems less likely associated with acceleration of the cell cycle than with other factors. Simple enucleation or curettage of these lesions may be inappropriate treatment.

The use of autogenous vein grafts for inferior alveolar and lingual nerve reconstruction.

PURPOSE: This study evaluated whether an autogenous vein graft forms a satisfactory conduit for nerve regeneration. PATIENTS AND METHODS: Fifteen patients received a total of 16 autogenous vein grafts to repair continuity defects of the inferior alveolar (6) and lingual nerves (10) nerves. All were treated between 4 and 10 months after injury. At surgery, the postresection defects ranged from 2 to 14 mm. All lingual nerves were repaired with saphenous vein grafts from an intraoral approach and all inferior alveolar nerves were repaired with facial vein grafts inserted from an extraoral approach. RESULTS: Lingual nerve repair in 3 cases where the gap between the nerve ends was 5 mm or less resulted in some return of sensation. In 7 cases where the gap was between 5 and 14 mm, there was no return of sensation. In the 6 inferior alveolar nerve repairs there was some return of sensation in all cases and there was good return of sensation in 3 cases. One patient redeveloped dysesthesia in the inferior alveolar nerve and subsequently had a neurectomy. Histologic material was available from this case. CONCLUSIONS: It appears that a vein graft can form a physiologic conduit for nerve regeneration. The results are more successful with shorter gaps, which indicates that, in some respects, the vein acts like a barrier membrane. The increased success rate in the inferior alveolar nerve repair may be because the vein remains straight and patent in the inferior alveolar canal. The lack of success with a long lingual nerve gap repair may be because the vein is collapsed or kinked by movement of the tongue, which may inhibit neural regeneration. Therefore, vein grafts should not be used for long lingual nerve continuity defects.

The use of enucleation and liquid nitrogen cryotherapy in the management of odontogenic keratocysts.

PURPOSE: This study evaluated the use of enucleation and cryosurgery in the management of odontogenic keratocysts. PATIENTS AND METHODS: This study involved a retrospective review of 26 patients. All of the patients received a combination of enucleation and cryosurgery. Postoperative follow-up consisted of clinical and radiographic examinations. RESULTS: Before enucleation and cryotherapy, 22 of the 26 patients had received previous treatment consisting of enucleation alone. The average time from initial treatment to recurrence was 6.2 years. Twenty-three cases occurred in the mandible, 22 in the posterior (proximal to the canine), and 1 in the anterior mandible. Three cases involved the maxilla. Three of the 26 patients (11.5%) developed a recurrence after treatment. The average time from treatment to recurrence in these 3 patients was 1.6 years (range, 1.2 to 1.9 years). The remaining 23 patients (88.5%) had no evidence of clinical or radiographic recurrence. The average time of follow-up was 3.5 years (range, 2.0 to 10.0 years). CONCLUSIONS: Based on these results, the combination of enucleation and liquid nitrogen cryotherapy may offer patients improved therapy in the management of odontogenic keratocysts.