Can Alloplastic Total Temporomandibular Joint Reconstruction be Used in the Growing Patient? A Preliminary Report.

INTRODUCTION: Although primarily reserved for adult patients, temporomandibular joint (TMJ) total joint reconstructive (TJR) surgery is rarely used in the pediatric population due to its many challenges; it is only performed after all other non-invasive or invasive procedures have been exhausted. Although autogenous grafting has been discussed in the literature, there is very little regarding synthetic or alloplastic materials. In this study, we performed alloplastic TMJ reconstruction on 5 patients with severe ankylosis due to various craniofacial deformities and prior traumatic injuries. MATERIALS AND METHODS: This is a retrospective case series analysis of skeletally immature patients who received alloplastic TMJ reconstruction for recurrent and advanced ankylosis. Our inclusion criteria were as follows: less than 16 years of age, diagnosis of TMJ ankylosis, skeletally immature patients, and unilateral/bilateral total alloplastic TMJ reconstruction. We used the maximum incisal opening (MIO) changes as 1 component to assess for functional improvement. RESULTS: Since many of these cases involved gross discrepancies from the normal variants, it was difficult to quantitatively compare the patients with one another. Nevertheless, we used cephalometric analysis to compare pre- and postoperative results on each patient. For this study, we used MIO as our primary assessment: the preoperative average for MIO was 7.4 mm, and the postoperative average 24 mm. CONCLUSION: It is our experience that the use of alloplastic material will not result in harm to either the growth of the mandible or patient's ability to achieve an improved MIO based on our long- and short-term results. These results demonstrate that for even complex craniofacial deformities and traumatic injuries, our patients experienced a significant improvement in MIO, 1 of the main indicators for TMJ function. We conclude that the alloplastic joint can provide a predictable pathway to restore patient's MIO and obviate the need for repeated surgeries, which can be a more challenging alternative with poorer outcomes.

Anatomical Location of Initial and Repeat Mandible Fractures: A 5-Year, Multi-Institution Retrospective Study.

PURPOSE: The purpose of the present study was to investigate new fracture patterns resulting from low velocity mechanisms in subjects who had previously fractured their mandible and had been treated with open reduction and internal fixation (ORIF) or closed reduction. METHODS AND MATERIALS: A multi-institutional retrospective cohort study was designed to analyze subjects presenting at 2 tertiary care centers with mandibular fractures with specific interest in subjects who had repeat mandible fractures. Variables recorded included demographic (age, sex, etc) data, fracture location of all fractures treated, and the location of previous fracture. Descriptive and bivariate analyses were completed of the data. RESULTS: The sample included a total of 492 subjects and 875 total fractures from both institutions. Four hundred fourty-four (91.1%) were male. The average age of all subjects was 36.4 ± 14.9 years. Twenty-six (5.28%) subjects were previously treated for a mandible fracture. All subjects' subsequent fractures occurred outside of previous ORIF except for 1 subject. Original fracture location (P = .596) and previous ORIF type (P = .689) did not influence if the subsequent fracture was within a site of previous ORIF. CONCLUSIONS: The present study demonstrates that repeat mandible fractures are relatively rare, likely to occur only 5% of the time at large tertiary care centers. The repeat fracture is not likely to occur in a site of previous ORIF, regardless of the ORIF modality. Furthermore, the fracture is likely to occur on the contralateral side. This is 1 of the largest data sets on repeat mandible fractures, which, given their rarity, are difficult to study.

Three-segment versus 2-segment surgically assisted rapid maxillary expansion.

OBJECTIVE: To compare the 2 surgically assisted rapid maxillary expansion (SARME) techniques, the conventional 2-segment osteotomy between maxillary central incisors and the 3-segment osteotomy between maxillary lateral incisors and canines bilaterally. Authors hypothesized that the 3-piece would provide better bone expansion. STUDY DESIGN: A pilot study was conducted; 19 patients were divided into 2 groups: conventional 2-segment osteotomy (10 patients) and 3-segment osteotomy (9 patients). Dental and skeletal measurements of the preoperative and postoperative cone beam computed tomography images were analyzed. Pre- and postoperative periodontal probing was performed, patients' cosmetic perception was evaluated in a colored visual analog scale (VAS), and surgical time was measured with a regular chronometer. RESULTS: Three-segment SARME resulted in greater bone expansion (5.12 vs 6.20 mm; P = .016), less molar inclination (7.16 vs 3.57 degrees; P = .028), better patient cosmetic perception (3.13 vs 7.68 in a VAS; P = .000), and longer surgical time (43 vs 52 minutes; P = .026). Furthermore, the 2-segment group presented necrosis of 1 central incisor. CONCLUSIONS: Results suggest that 3-piece SARME is more effective for bone expansion of the maxilla.

Arthrocentesis versus nonsurgical methods in the management of temporomandibular joint closed lock and pain: a double-blind randomized controlled trial.

OBJECTIVE: The present double-blind randomized clinical trial aimed to compare the efficacy of conservative treatment and articular lavage, either alone or combined, to reduce joint pain and improve mandibular opening. STUDY DESIGN: The sample consisted of patients presenting with limited mouth opening and joint pain. The diagnosis was made according to the diagnostic criteria for temporomandibular disorders guideline and confirmed by magnetic resonance imaging. Sixty patients were selected and randomly allocated to 4 groups of 15 patients each with different treatments: group A (conservative), group B (conservative + medication), group C (arthrocentesis), and group D (arthrocentesis + medication). The groups were compared in terms of maximal interincisal opening and pain. RESULTS: The average age of the patients was 34.17 ± 13.1 years, 88.1% were women, 72.9% had internal derangement, 54% had joint sounds, and 55.9% presented with locking. Clinical improvement was noted in all parameters compared with baseline in all groups (P < .005), but no significant differences were observed when the groups were compared (P > .05). CONCLUSIONS: Both arthrocentesis and conservative modalities were efficient treatments to reduce joint pain and increase mandibular opening.

Impact of orthognathic surgery on quality of life and comparison of patients' postoperative experience after single- and double-jaw surgery: a longitudinal study.

OBJECTIVE: To evaluate the impact of orthognathic surgery on quality of life (QoL) and to compare single- and double-jaw surgeries in terms of ratio and patient perceptions of the postoperative period. STUDY DESIGN: A prospective, longitudinal observational study was conducted. The short form Oral Health Impact Profile (OHIP-14) and the Orthognathic Quality of Life Questionnaire (OQLQ) were applied preoperatively and 6 months postoperatively to evaluate oral health-related QoL (OHRQoL). Additionally, patient perceptions of the immediate postoperative period were assessed at the first and fourth week after surgery. RESULTS: One hundred consecutive patients were recruited and assigned to the single-jaw group (n = 24) or the double-jaw group (n = 76) according to the characteristics of each facial or occlusal deformity. The questionnaires showed lower scores for both groups after surgery, indicating significant benefits to OHRQoL. The whole sample OHIP-14 mean total scores decreased from 10.5 to 2.8 (P < .001, d = 1.35), whereas OQLQ showed a decrease from 48.4 to 11.6 (P < .001, d = 1.75). CONCLUSIONS: Orthognathic surgery can improve OHRQoL, and long-term benefits outweigh the risks and discomfort associated with the treatment.

Methicillin-resistant Staphylococcus aureus and antibiotic use in septorhinoplasty: case report and review of literature.

Septorhinoplasty is a commonly performed procedure for facial aesthetics and obstructed nasal breathing. There have been only 4 reported cases of methicillin-resistant Staphylococcus aureus (MRSA)-associated postoperative complications following septorhinoplasty reported in the literature across all specialties. In this article, we report a case of MRSA-associated infection after an uncomplicated septorhinoplasty. Risk stratification and outcome of treatment are described, followed by a review of the current literature. We discuss the epidemiology of MRSA colonization, prophylactic use of antibiotics in septorhinoplasty, previously reported MRSA-associated septorhinoplasty infections, and management of complications. There are no current standards for MRSA decolonization before septorhinoplasty. Finally, we offer recommendations for patients at high risk for MRSA infection undergoing septorhinoplasty and considerations for treatment of MRSA infections should they occur after septorhinoplasty.

Maxillary sinus augmentation.

Attention to the principles of bone grafting, bone healing, and maxillary sinus physiology as well as anatomy is critical to the successful placement of dental implants in the posterior maxilla. The integration of these principles must take into account the restorative dental requirements and the patient's autonomy in guiding implant reconstruction. As in so many clinical disciplines, additional research is needed to provide better guidance for clinicians. Despite some gaps in our knowledge, however, sinus augmentation procedures have proven to be safe and effective and have permitted the placement of implants in sites that would have otherwise been impossible to treat. This article summarizes techniques and technologies related to maxillary sinus augmentation.

Management of impacted teeth in children.

Ankylosis remains one of the major complications associated with impacted teeth in children. Orthodontically-assisted eruption of an ankylosed tooth may intrude or displace the adjacent teeth. Children who undergo orthodontically assisted eruption should be followed closely to ensure that movement of an impacted tooth is occurring. In general, the removal or assisted eruption of impacted teeth in children requires a thoughtful interdisciplinary evaluation between the surgeon and orthodontist/primary dental care provider. Factors that must be considered include operative feasibility, orthodontic management, future growth, and psychosocial considerations. The use of emerging technology, such as cone beam CT and skeletal anchorage, should better equip surgeons to navigate the anatomy three-dimensionally and provide assistance in management of difficult cases.

Aspiration and ingestion in dental practice: a 10-year institutional review.

BACKGROUND: This article is an institutional retrospective review of incidents involving aspiration and ingestion of dental foreign objects at a large multidisciplinary dental educational facility. It was undertaken to determine which dental procedures were more likely to involve aspiration or ingestion, as well as to evaluate the outcome of these adverse incidents. METHODS: The inclusion criteria involved all patients who were documented to have experienced loss of dental instruments or material behind the posterior pharynx during a 10-year consecutive period. The dental and medical records of these patients were analyzed, and the outcomes of the adverse events fell into three categories: aspiration, ingestion, or neither aspirated nor ingested. The authors also noted the type of dental instrument and the specialty or area of dentistry in which this event occurred. RESULTS: There were 36 documented cases. Twenty-five of these were instances of ingestion and one was an aspiration. In 10 cases, aspiration and ingestion were ruled out through radiographic examination or the object was retrieved from the patient's mouth. CONCLUSIONS: Fixed prosthodontic therapy had the highest number of incidents of adverse outcomes. Ingestion was a more prevalent outcome than aspiration. Dental procedures involving single-tooth cast or prefabricated restorations involving cementation have a higher likelihood of aspiration. CLINICAL IMPLICATIONS: The implications for clinical practice include the recognition of risk that dental therapy demands in regard to the airway and posterior pharynx, documentation and follow-up of adverse outcomes, and the use of preventive measures such as rubber dams or gauze throat screens or floss ligatures.

Subcranial procedures in craniofacial surgery: the Le Fort III osteotomy.

The esthetic stigmata and functional impairments associated with craniofacial deformities have long challenged surgeons in the management of deficiencies of the middle third of the face. By their very nature, craniofacial anomalies are repetitive patterns of deformity that affect the different functional and esthetic subunits of the facial hard and soft tissues. Although numerous procedures exist for the management of the various craniofacial malformations in the middle third of the facial skeleton, only the subcranial Le Fort III osteotomy addresses all of the functional and esthetic components of total midface deficiency, when considering an extracranial approach for surgical correction of the deformity. This article discusses craniofacial dysostosis and total midface deficiency and the techniques and care involved with both.

Craniofacial dysostosis syndromes: stages of reconstruction.

The term "craniofacial dysostosis" is used in a general way to describe syndromal forms of craniosynostosis. These disorders are characterized by sutural involvement that not only includes the cranial vault but also extends into the skull base and midfacial skeletal structures. Craniofacial dysostosis syndromes have been described by Carpenter, Apert, Crouzon, Sathre-Chotzen, and Pfeiffer. Although the cranial vault and cranial base are believed to be the regions of primary involvement, there is also significant impact on midfacial growth and development. In addition to cranial vault dysmorphology, patients with these inherited conditions exhibit a characteristic "total midface" deficiency that is syndrome specific and must be addressed as part of the staged reconstructive approach.

Treacher Collins syndrome: comprehensive evaluation and treatment.

When contemplating the reconstructive options for patients with Treacher Collins syndrome, surgeons must recognize the complex interplay between growth of the craniofacial region and the possible effects of early surgery on further growth. Consequently, surgical procedures for the deformities in Treacher Collins syndrome are staged based on the dysmorphology and the growth velocity of each anatomic region. This article reviews the evaluation and management considerations for patients with Treacher Collins syndrome.

The use of risdon cables in pediatric maxillofacial trauma: a technique revisited.

Although less common than adult fractures, fractures of the pediatric maxillofacial skeleton present unique challenges. Different considerations including variations of anatomy including tooth buds, dental variations, as well as considerations for future growth must be addressed. When traditional techniques to treat adult fractures are applied for securing intermaxillary fixation (IMF) such as arch bars, difficulty arises because the primary teeth are shorter and conventional arch bar techniques may slip off intra or postoperatively. We present a technique to achieve both IMF as well as interdental stability using a Risdon cable. Although this technique is not new, we present it as our preferred method for treating pediatric fractures of the facial skeleton where IMF must be accomplished.