Degree of Compression of the Inferior Alveolar Canal on Cone-Beam Computed Tomography and Outcomes of Postoperative Nerve Injury in Mandibular Third Molar Surgery.

PURPOSE: Cone-beam computed tomography (CBCT) offers the advantage of a 3-dimensional representation of the anatomic relationship of the mandibular third molar tooth and the inferior alveolar canal (IAC), as compared to a panoramic radiograph. We hypothesized that a novel method of categorizing the degrees of compression of the IAC were reliable predictors for postoperative nerve injuries. METHODS: We conducted a retrospective analysis of the outcomes in third molar surgery for patients who obtained a CBCT scan in additional to a plain film radiograph over a 12 months period and underwent surgical removal of their mandibular third molars; 257 consecutive patients were identified, and 416 mandibular third molars were surgically removed. RESULTS: Patients who had severe compression of the inferior alveolar canal (IAC) on CBCT imaging had a significantly increased risk of a postoperative IAN injury (P = .0068, OR = 3.47, 95% CI: 1.40 to 8.54) and accounted for 52.17% of all IAN injuries. Ninety-one percent of all cases of postoperative nerve injury occurred in female patients. The mean age of patients with a postoperative IAN injury (30.2 years) was significantly higher than those without injury 26.0 years; (P = .016, 95%CI: 25.11 to 33.80) CONCLUSIONS: In addition to patient factors, assessment of the degree of compression on a preoperative CBCT image is a useful tool for predicting outcomes in mandibular third molar surgery. In cases of severe compression of the IAC, patients are at a significantly increased risk of postoperative IAN injury.

A Comparison of Immediate and Delayed Dental Implant Placement in Head and Neck Surgery Patients.

PURPOSE: Implant-supported dental prostheses offer numerous benefits for patients after ablative procedures of the head and neck region, including restoration of function, improved self-esteem and body satisfaction, and overall quality of life. Increased experience is emerging with immediate placement of implants at the time of ablative surgery compared with the traditional delayed approach. The authors sought to identify variables affecting survival of osseointegrated dental implants in such patients and to assess the impact of timing of implant insertion (immediate vs delayed) on the time until final prosthesis insertion. MATERIALS AND METHODS: Implant survival was assessed based on different factors: immediate versus delayed implants, benign versus malignant disease, postoperative radiotherapy, smoking status, alcohol status, age, 1- versus 2-stage surgery, hyperbaric oxygen therapy, and implant placement into native bone versus into osseous free flap reconstruction. Time to final prosthesis insertion was compared between immediate and delayed implant placement. RESULTS: The study included 20 patients who received a total of 102 implants (39 immediate, 63 delayed). There were 7 failed implants (overall survival, 93.14%). There was no statistically relevant difference in implant survival between any of the groups assessed. However, there was a significant decrease in time to final prosthesis insertion for those patients receiving immediate implants compared with those who underwent delayed implant placement (321 days; standard error, 46.5 vs 726 days; standard error, 45 days; P < .0001). CONCLUSIONS: Immediate implant placement is an effective approach to the prosthetic rehabilitation of patients undergoing ablative procedures of the jaws, which shortens time to final prosthesis placement without adversely affecting overall implant survival.

Risk factors for permanent injury of inferior alveolar and lingual nerves during third molar surgery.

PURPOSE: The purpose of this study was to assess the incidence of and risk factors for permanent neurologic injuries to the inferior alveolar nerve (IAN) or lingual nerve (LN) after the removal of third molars. This report also describes the use of a Clinical Incident Review (CIR) process, allowing close monitoring of all patients with neurologic injuries as a result of dentoalveolar surgery. MATERIALS AND METHODS: A database associated with a CIR process at the Royal Dental Hospital of Melbourne from January 2006 through December 2009 was assessed. Factors assessed included gender, age, operator class, method of anesthesia, spacial relation, depth of impaction, ramus relation, proximity of the IAN on orthopantomogram, cone-beam computed tomographic usage, and side of injury. RESULTS: During this 4-year period, 11,599 lower third molars were removed in 6,803 patients. The incidence of an IAN injury was 0.68%, and the incidence of an LN injury was 0.15%. Important risk factors for permanent IAN injury were increasing age, surgery performed by staff dentists, type of anesthesia, and mesioangular impactions. The mean time of complete resolution was 4.3 months. No factors were found to statistically increase the risk of LN injury, although most injuries were seen in patients with a distoangular impaction. CONCLUSION: The overall incidences of IAN and LN injuries were low. Some risk factors for permanent IAN nerve injury were identified. Important risk factors for permanent IAN injury were increasing age (≥25 yr old), surgery performed by staff dentists, surgery under general anesthesia, and mesioangular impaction. No factors were found to statistically increase the risk of LN injury.

Assessment of laminin-5 in oral dysplasia and squamous cell carcinoma.

PURPOSE: Laminin-5 is an important protein in the establishment of an intact basement membrane. The aims of this study were to assess the expression of laminin-5 (γ2 chain) using cyclin D1 and Ki-67 in hyperplastic oral mucosal lesions, oral dysplasia, and squamous cell carcinoma (SCC). MATERIALS AND METHODS: Paraffin-embedded tissue blocks of 134 patients were stained for laminin-5, cyclin D1, and Ki-67 using immunohistochemistry and assessed by virtual microscopy. Statistical analysis was performed using Kruskal-Wallis tests and Mann-Whitney U tests for post hoc assessment. RESULTS: Laminin-5, cyclin D1, and Ki-67 were found to have significant differences in expression for the different categories of dysplasia, SCC, and hyperplasia (P < .001). Cyclin D1 and Ki-67 expression levels were significantly increased in moderate and severe dysplasia and SCC, with no significant difference in expression between hyperplasia and mild dysplasia or between biopsies of severe dysplasia and SCC. Laminin-5 expression was only significantly increased in SCC, confirming it as a marker of malignant transformation and invasion. CONCLUSIONS: The results of this study indicate that overexpression of laminin-5 is found only in SCC and not dysplastic lesions. Therefore, laminin-5 has potential as a marker for the intraoperative assessment of cancer excision margins and could be used as a target for chemotherapeutic agents.

Outcomes of patients with maxillofacial osteosarcoma: a review of 15 cases.

PURPOSE: To assess clinical behavior, response to treatment, and factors affecting survival in maxillofacial osteosarcoma treated at a tertiary referral center. PATIENTS AND METHODS: Ethics-approved retrospective review of clinical and pathological records was undertaken for 15 patients managed by the Royal Melbourne Hospital Head and Neck Oncology Tumor Stream. RESULTS: Treatment was a combination of surgery and chemotherapy. Chemotherapy was given as adjuvant, neoadjuvant, or in combination. The overall 2-, 5-, and 15-year disease-free survival rates in this study were 92%, 74%, and 74%, respectively. Using Kaplan-Meier analysis with log rank tests, increasing T stage (P = .01) and positive margins (P = .003) were found to affect survival significantly. Neoadjuvant chemotherapy was not significantly associated with tumor necrosis or improved survival. CONCLUSIONS: Tumor size and adequacy of local control were found to be the most important predictors of outcome.

Factors affecting incidence of dry socket: a prospective community-based study.

Dry socket, or alveolar osteitis, can occur because of the removal of teeth. No clear etiology has been acknowledged; however, numerous risk factors have been proposed and tested. We report on the results of a prospective, multicenter study of the incidence and factors affecting the occurrence of alveolar osteitis at the Royal Dental Hospital of Melbourne and Community Dental Clinics in Melbourne, Australia. Ethics approval was gained from the University of Melbourne and Dental Health Services Victoria. The data were analyzed in a descriptive fashion, and the factors affecting alveolar osteitis were assessed using logistic regression analysis. The incidence of alveolar osteitis was 2.3% of all teeth extracted, with 4.2% of all patients experiencing alveolar osteitis in a public dental setting. Multivariate analysis revealed operator experience, perioperative crown and root fractures, periodontal disease, posterior teeth, and, interestingly, the use of mental health medications to be significant independent risk factors for the development of alveolar osteitis. No alveolar osteitis was reported in patients taking antibiotics, the oral contraceptive pill, bisphosphonates, or oral steroid drugs. Smoking and extraction technique (either operative or nonoperative) were also not found to significantly affect the development of alveolar osteitis.

Unexpected temporary mental nerve deficit after extraction of mandibular first molar: case report.

UNLABELLED: Temporary neurologic deficit affecting the distribution of the left mental nerve was reported in a warfarinized, diabetic patient who had a history of previous CVA with right-sided body weakness. The neurologic deficit was reported following routine extraction of a left mandibular first molar. Recovery of sensation began six weeks after the procedure. Possible mechanisms and preventive measures are discussed. CLINICAL RELEVANCE: The reader should understand that mental paraesthesia can be an unexpected outcome in the most routine of mandibular extractions.

Treatment of oral leukoplakia with carbon dioxide and potassium-titanyl-phosphate lasers: a comparison.

PURPOSE: To determine whether the treatment of oral leukoplakia with potassium-titanyl-phosphate (KTP) lasers versus CO(2) lasers results in lower recurrence rates. MATERIALS AND METHODS: Retrospective data were collected from the records of 30 patients (mean age 75.6 years) with 35 primary oral leukoplakia who had their lesions ablated by KTP laser, and 45 patients (mean age 59.9 years) with 59 primary oral leukoplakia who had CO(2) laser treatment. The recurrence rates of lesions between these 2 groups was then compared. RESULTS: A statistically significant (P = .049) reduction in recurrence rates for those patients treated with KTP lasers versus CO(2) lasers was found. CONCLUSION: The use of KTP lasers for the treatment of oral leukoplakia may result in lower recurrence rates than when using CO(2) lasers.

Assessing the impact of computerised and written advice in changing the habit and behaviour of alcohol use in patients who have suffered alcohol-related facial injuries-a pilot study.

PURPOSE: Alcohol screening and a brief intervention (SBI) can be effective in changing harmful drinking behaviour and reducing the chance of future alcohol-related traumas. However, there is no standardised method in its application. This study aims to deliver a novel method of SBI to patients with alcohol-related facial fractures and to assess changes in their alcohol intake and attitudes to drinking following this intervention. METHODS: Twenty consecutive patients at two Victorian Hospitals were consented to undergo a novel SBI program. This study analysed the results of the initial survey and the follow-up survey completed at least 3 months later. RESULTS: Of the 20 patients recruited for the initial survey, 18 returned for the follow-up (90% response rate). All patients were males, 50% were aged between 18 and 29 years, 61% involved in interpersonal violence, 56% sustained mandibular fractures and 89% underwent surgery. The alcohol risk score increased in the follow-up survey; however, the relationship is not statistically significant. A high proportion of the patients were still unaware of their risk. Patients showed greater awareness of their drinking and willingness to accept help and more readiness to accept written advice rather than computerised materials. CONCLUSION: This study found a high rate of acceptance among trauma patients to the intervention program. Although there was no significant change in the risk scores between the initial and follow-up surveys, certain subgroup was more amenable to the intervention given. There is generally an improvement in the attitudes towards and knowledge of harmful drinking.

Brief alcohol intervention in alcohol involved facial fracture patients-a survey of patient attitudes to screening and intervention.

PURPOSE: Alcohol intoxication is an important contributor to traumatic facial injuries. The period following injuries afford clinicians a useful window of opportunity to provide alcohol screening and brief intervention (SBI) which may affect changes in patients' future drinking behaviour. Although SBI has been reported to decrease at risk drinking and potentially trauma recurrence, it is not routinely utilised in most clinical settings in the world. This study aims to assess utilisation of, as well as patients' knowledge and attitude towards SBI in the management of patients presenting with alcohol-related facial fractures. METHODS: Twenty consecutive patients who presented to Western Health with facial fractures who met selection criteria were offered an alcohol screening and survey questionnaire. RESULTS: Ninety percent of patients were male and 50% were aged between 19 and 34. ASSIST score showed 65% were in the moderate risk category; 75% reported this was their first admission with alcohol related trauma. Although 75% acknowledged alcohol as a main cause of injury, only 40% agreed they drink too much. Forty-four percent felt that talking to a healthcare worker might help and 33% would consider accepting help. Forty-seven percent felt reading materials would be helpful in changing future drinking habits. Whilst 63% would like to know safe drinking limit, only 45% would like to have a discussion about alcohol-related harms. CONCLUSIONS: Most patients presented in this survey were in moderate risk category who are amenable to behavioural change with provision of SBI. However, there is resistance to implementation of this intervention due to lack of knowledge, self-awareness and willingness to change. Nonetheless, patients are prepared to accept advice from clinicians and some formats of intervention. It is important to formulate a simple screening questionnaire and intervention strategy that are easy to administer to affect positive changes in patients with harmful drinking behaviours.

Retrospective Study of Survival of Extraoral Endosseous Craniofacial Implants in Head and Neck Surgery Patients.

PURPOSE: To determine the survival rate of implants placed in different craniofacial locations and factors affecting survival. MATERIALS AND METHODS: This study retrospectively reviewed a consecutive series of patients treated at the Royal Melbourne Hospital who received craniofacial implants for an array of benign and malignant conditions. Implant survival per site and cumulative survival were determined. Surgical and implant variables were assessed using the Kaplan-Meier and Cox Proportional Hazards Models. RESULTS: Fifty-two patients had 156 implants placed to reconstruct the nose, orbit, and ears. A total of 43 implants failed (overall survival: 72.4%) in the orbital (29/63, failure rate: 46%) and auricular sites (14/70, failure rate: 17%). No implants failed in the nasal site (0/9). Three-, 5-, and 10-year cumulative survival was also determined. Independent risk factors for decreased survival included postoperative radiation therapy (P = .005, RR: 3.2, 95% CI: 1.4 to 7.0), implants placed in the orbit (P = .004, RR: 5.0, 95% CI: 1.6 to 15.2), and implants that were not loaded with a prosthesis (P = .007, RR: 2.7, 95% CI: 1.3 to 5.4). CONCLUSION: Failure rates varied according to site in this cohort of patients. A number of independent risk factors affecting implant survival in extraoral sites were identified.

Immunohistochemistry of Five Molecular Markers for Typing and Management of Ameloblastomas: A Retrospective Analysis of 40 Cases.

PURPOSE: The aims of this study are to elucidate if molecular markers can be used to differentiate between the two main types of ameloblastoma (unicystic and solid/multicystic), and to determine whether a biologically 'less-aggressive' subtype exists. METHODS: A retrospective analysis of 33 solid/multicystic ameloblastomas and six unicystic ameloblastomas was completed using immunohistochemistry for five molecular markers: P16, P53, MMP-9, Survivin, and Ki-67. Tumors were graded as either negative or positive (mild, moderate, strong), and the results were related to both ameloblastoma subtypes and outcomes following treatment. RESULTS: Unicystic ameloblastomas were more likely to test strongly positive for P53 than solid/multicystic ameloblastomas (p < 0.05), whereas the latter were more likely to be negative for Survivin (p < 0.05). Solid/multicystic and Type 3 unicystic ameloblastomas that were positive for P16, but also negative for MMP-9 and Survivin, were less likely to recur than all other tumors (p < 0.05). The proliferation index of an ameloblastic carcinoma (11 %) was shown to be higher than benign ameloblastomas (4.5 %). CONCLUSIONS: Immunohistochemistry can be valuable in lesions where histological sub-typing of an ameloblastoma is unclear. A biologically 'less-aggressive' subtype may exist, and hence further research into this area is required.

Kimura's disease: an uncommon cause of head and neck masses with potentially serious sequelae.

Kimura's disease (KD) typically presents as a mass in the head and neck region in association with eosinophilia and elevated serum IgE. Excisional biopsy is often required in order to obtain an adequate sample for histological diagnosis and exclude malignancy. If suspected, patients should also be investigated for renal involvement as this may complicate KD. Treatment options include surgical excision and medical therapies such as corticosteroids depending on the extent and severity of disease.

Synchronous oral and gastric carcinoma. An incidental finding on Percutaneous Endoscopic Gastrostomy insertion.

Synchronous oral and gastric carcinoma in the western world is rare. We report a case of synchronous oral squamous cell carcinoma (SCC) and gastric adenocarcinoma which was found as an incidental finding during placement of a Percutaneous Endoscopic Gastrostomy (PEG) before resection of the oral tumour.

Bilateral submandibular gland oncocytoma in a patient with multiple endocrine neoplasia 2B syndrome and neurofibromatosis type 1: an unusual case.

Oncocytomas are unusual neoplasms of the head and neck that occur mainly in the parotid gland. The authors report a case of bilateral submandibular gland oncocytoma in a patient with multiple endocrine neoplasia 2B syndrome and neurofibromatosis type 1. Histopathology of the resection specimens demonstrated lymphovascular invasion but no other aggressive features. This was a highly unusual feature in an otherwise rare benign tumour.

An immunohistochemical analysis of cell cycle markers in oral mucosal dysplastic lesions treated by laser therapy. A pilot study.

INTRODUCTION: Over the past 15 years, dysplastic oral mucosal lesions have been treated by laser ablation with variable success. A recent study have shown that the type of laser utilized may be important for patient outcome, however, it may also be changes at a cellular level that could be an important factor in determining recurrence outcome. The aims of this study were to assess cellular markers related to oral dysplastic lesions treated by two different laser types. METHODS AND MATERIALS: Twenty patients with a histopathological diagnosis of dysplasia treated with laser ablation between the years 1992 and 2003 were assessed. Tissue blocks of the original diagnostic biopsy specimens were stained with specific cell cycle markers (Cyclin-D1 and Ki67) via immunohistochemistry and presence of the marker were analysed by virtual microscopy. Patients were assessed according to grade of dysplasia [(mild vs. moderate vs. severe) and the type of laser used (Potassium Titanyl Phosphate (KTP) vs. Carbon Dioxide (CO(2))]. RESULTS: No significant difference in Cyclin-D1 and Ki67 levels were found between the two groups with different grades of dysplasia, however, decreased Cyclin-D1 was found in those patients treated with KTP laser (P = 0.028). CONCLUSIONS: The findings of the present study may indicate cell cycle makers such as Cyclin-D1, may be responsible for the behaviour of dysplastic lesions treated with laser therapy, rather than the type of laser itself, which was reported in previous studies.

Submental intubation in orthognathic surgery: initial experience.

Submental intubation is a technique for use in maxillofacial trauma, which allows precise assessment of changes to the nasolabial complex, midlines, cants, and incisal display in patients having maxillary orthognathic surgery. We report our initial experience of it used as an adjunct in the management of orthognathic surgery in a series of 44 patients.