Comparison of high-resolution MRI and SPECT bone scintigraphy for noninvasive imaging of the temporomandibular joint.

Prospective evaluation by magnetic resonance imaging (MRI) and both single photon emission computed tomography (SPECT) and planar bone scintigraphy was undertaken in 31 temporomandibular joints (TMJs) of 21 symptomatic patients. When compared with the results of subsequent arthrography, MRI (0.88) was more sensitive than SPECT (0.76) or planar (0.56) scintigraphy for detection of internal derangement of the TMJ. A diagnostic sensitivity of 0.96 was achieved when the results of either MRI or SPECT was considered evidence of internal joint derangement. Five symptomatic TMJs, clinically thought to be abnormal, were positive on SPECT but showed no evidence of anterior disk displacement at the time of arthrography. In such instances, SPECT may be detecting functionally significant altered joint mechanics that are not evident on anatomic imaging of the TMJ.

The temporal branch of the facial nerve: how reliably can we predict its path?

A thorough examination of the temporal branch of the facial nerve was performed to characterize precisely the number of rami crossing the zygomatic arch and their location with respect to bone and soft-tissue landmarks. Fresh cadaver dissection was performed in 12 facial halves, dissecting the facial nerve superiorly from the stylomastoid foramen to identify all branches crossing the zygomatic arch. There were a median of three (range two to four) rami of the temporal branch crossing the lower aspect of the zygomatic arch, with distinct anterior and posterior divisions identified in each dissection. In 8 of the 12 dissections, one or more separate middle divisions of the nerve also were seen at the inferior aspect of the zygomatic arch. Superior to the zygomatic arch, frequent interconnections were noted between all divisions of the temporal branch, but no connections were noted to other branches of the facial nerve. Previous descriptions of the course of the temporal branch based on soft-tissue landmarks most closely correlated with nerve rami that were found in the present study to be located within the anterior division of the nerve. On crossing the inferior aspect of the zygomatic arch, the anterior and middle divisions of the temporal branch were located a median of 12 and 4 mm anterior to the articular eminence, respectively; the posterior division ranged in location from 10 mm posterior to 7 mm anterior to the articular eminence. The range over which rami of the temporal branch crossed the inferior aspect of the zygomatic arch was equally divided anterior and posterior to the articular eminence and covered up to 50 percent of the total length of the zygomatic arch. The present study confirms that the temporal branch is not a single nerve branch but consists of multiple rami that cross the zygomatic arch anywhere for over half the length of its inferior border. Techniques for localizing the nerve based on reference points from two soft-tissue landmarks are therefore unreliable.

Reconstruction of lower third of face with three simultaneous free flaps.

A case of massive osteoradionecrosis is presented that required angle-to-angle resection of the mandible and replacement of skin of the chin and neck as well as the entire floor of the mouth. In this heavily irradiated patient, three microvascular free flaps were transferred in one operation. A large radial forearm flap was used to reconstruct the floor of the mouth. A second large radial forearm flap was used to reconstruct the chin and neck defects and a fibular osseous flap was used to reconstruct the mandible. All wounds healed primarily. For extremely complicated and large defects, the transfer of multiple free flaps may provide the best reconstruction.

Posterior cephalometric radiographic analysis in obstructive sleep apnea.

Our objective was to evaluate the relationship between posterior facial cephalometric measures and obstructive sleep apnea syndrome (OSAS). We used a consecutive sample of 60 patients with OSAS who underwent upright lateral cephalograms, uvulopalatopharyngoplasty (UPPP), and preoperative and postoperative polysomnography. Successful responders to UPPP were arbitrarily defined as having a respiratory disturbance index reduced to fewer than 20 events per hour. Standard cephalometric measurements were used. Posterior facial height measures were constructed, based on a plane perpendicular to the Frankfort horizontal placed at hyoidale. The total and lower airway lengths were shorter and posterior mandibular height was longer in UPPP responders compared to nonresponders (p < or = .05). There was no difference between the two groups by standard cephalometric measurements. Responders and nonresponders to UPPP have significant differences in posterior airway measures that are not reflected in standard cephalometric measures. Airway length likely is a critical factor in OSAS and surgical response.

Odontogenic tumors that mimic a dentigerous cyst.

Hyperplastic follicular tissue and a dentigerous cyst are the two most common entities associated with the crown of an impacted tooth. However, other diagnostic possibilities, including odontogenic tumors should also be considered in the differential diagnosis of a pericoronal radiolucency. This article presents three cases of radiolucent lesions that were histologically diagnosed as an odontogenic tumor, and stresses the importance of histological evaluation of all pericoronal radiolucencies.

Late reaction to silicone following reconstruction of an orbital floor fracture.

This report presented the clinical and radiographic findings, the surgical management, and the histologic features of a chronic inflammatory lesion that developed in response to a Silastic orbital floor implant placed 13 years previously. A review of the literature supported the fact that implanted solid film polymers can precipitate a continuous, chronic inflammatory response that is dynamic and that may be exacerbated by numerous factors.

A simplified technique of inferior border wiring in the sagittal split osteotomy.

The inferior border wire, as originally described by Booth, is a well-accepted means of fixation of the proximal and distal segments in the sagittal split osteotomy. However, it appears that there is some criticism of the technique because of the difficulty in placing drill holes at the appropriate position and angulation and subsequent difficulty with passage of a fixation wire. The technique presented here eliminates the technical difficulties and provides for a rapid, safe, and stable fixation.

The effects of intra-articular deposition of betamethasone in the goat temporomandibular joint.

PURPOSE: This study evaluated the response of the articular surfaces of the normal goat temporomandibular joint (TMJ) to intra-articular injections of betamethasone suspension. METHODS: Thirty female goats were divided into four experimental groups of seven each and one control group of two animals. The design resulted in 24 joints receiving from one to nine weekly injections of betamethasone suspension, 0.085 mg/kg. The 24 contralateral joints received an identical array of saline injections. In the remaining 12 joints, four were unilaterally injected with saline, four were unilateral uninjected joints, and four were bilateral uninjected joints. All of the joints were inspected grossly and histologically assessed for any intra-articular changes associated with corticosteroid injections. RESULTS: Comparative examination of the gross and histologic features of the injected joints and the eight normal joints showed no significant adverse effects on nondiseased TMJs. CONCLUSION: Intra-articular injection of betamethasone suspension at the dosage and delivery rate used had no harmful effects on the TMJs of nondiseased adult female goats. Because of possible differences between species, these results should not be taken as an indication that betamethasone suspension will not have adverse effects in the human TMJ. These findings support the need for further investigations into the physical and biochemical responses of normal and diseased articular fibrocartilage to different glucocorticosteroids at various concentrations and delivery rates using the goat and other animal models.

Final report of the FOPE II Pediatric Generalists of the Future Workgroup.

The Future of Pediatric Education II (FOPE II) Project was a 3-year, grant-funded initiative, which continued the work begun by the 1978 Task Force on the Future of Pediatric Education. Its primary goal was to proactively provide direction for pediatric education for the 21st century. To achieve this goal, 5 topic-specific workgroups were formed: 1) the Pediatric Generalists of the Future Workgroup, 2) the Pediatric Specialists of the Future Workgroup, 3) the Pediatric Workforce Workgroup, 4) the Financing of Pediatric Education Workgroup, and 5) the Education of the Pediatrician Workgroup. The FOPE II Final Report was recently published as a supplement to Pediatrics (The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics. 2000;105(suppl):161-212). It is also available on the project web site at: This report reflects the deliberations and recommendations of the Pediatric Generalists of the Future Workgroup of the Task Force on FOPE II. The report looks at 5 factors that have led to changes in child health needs and pediatric practice over the last 2 decades. The report then presents a vision for the role and scope of the pediatrician of the future and the core attributes, skills, and competencies pediatricians caring for infants, children, adolescents, and young adults will need in the 21st century. Pediatrics 2000;106(suppl):1199-1223; pediatrics, medical education, children, adolescents, health care delivery.