A systematic review and meta-analysis of the surgical outcomes in patients with osteochondroma of mandibular condyle.

Many options exist in the diagnosis and management of condylar osteochondroma. The purpose of this study was to provide a congregate information concerning treatment of the osteochondroma involving the mandibular condyle. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and Cochrane database until February 2022. Twenty-seven studies were included for the final review. The review included 439 patients who underwent surgical management for mandibular condylar osteochondroma. The position of osteochondroma was mentioned in 13 studies. Preauricular, retromandibular, endaural, submandibular, transzygomatic, and intraoral approaches were used for approaching the tumor. Surgical techniques included resection, conservative condylectomy, and total condylectomy. Concomitant orthognathic surgery was performed along with tumor resection in 19 studies. In the entire review, the recurrence rate was 0.22% (1/439). The results of the meta-analysis showed that 2 studies reported significant malocclusion events after surgical therapy. Total joint replacement after tumor resection has a higher improvement in maximal mouth opening (8 mm) compared with vertical ramus osteotomy and no reconstruction groups, which have similar improvements (6 mm). The mainstay of treatment of osteochondroma is surgical excision either as condylectomy or conservative condylectomy. Among the various reconstruction modalities, total joint replacement showed better improvement in mouth opening. Adjunct procedures like orthodontic and orthognathic surgery have an important role in holistic management of severe cases. The treating surgeon must choose the surgical procedures in a pragmatic way.

Prolonged Hypophosphatemia and Intensive Care After Curative Surgery of Tumor Induced Osteomalacia: A Case Report.

Introduction: Rare FGF23-producing mesenchymal tumors lead to paraneoplastic tumor-induced osteomalacia (TIO) presenting with phosphate wasting, hypophosphatemia, chronic hypomineralization of the bone, fragility fractures and muscle weakness. Diagnosis of TIO requires exclusion of other etiologies and careful search for a mesenchymal tumor that often is very small and can appear anywhere in the body. Surgical removal of the tumor is the only definitive treatment of TIO. Surgical complications due to chronic hypophosphatemia are not well recognized. Case Description: The current case describes severe fragility fractures in a 58-year-old woman, who lost her ability to walk and was bedridden for two years. First, the initial diagnostic laboratory work-up did not include serum phosphorus measurements, second, the suspicion of adverse effects of pioglitazone as an underlying cause delayed correct diagnosis for at least two years. After biochemical discovery of hyperphosphaturic hypophosphatemia at a tertiary referral centre, a FGF23-producing tumor of the mandible was discovered on physical examination, and then surgically removed. Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for ventilation support, intensive care and phosphate supplementation. After two years of rehabilitation, the patient was able to walk short distances. The tumor has not recurred, and serum phosphate concentration has remained within normal limits during 3.5 years of follow-up. Conclusions: The case report illustrates knowledge gaps in the diagnostic work-up of rare causes of low bone mass and fragility fractures. Compared to other low phosphate conditions, surgical recovery from TIO-induced hypophosphatemia warrants special attention. Increased alkaline phosphatase concentration may indicate impaired postsurgical recovery due to prolonged hypophosphatemia, underlining the need for proactive perioperative correction of hypophosphatemia.

Tumor-induced Osteomalacia in a 3-Year-Old With Unresectable Central Giant Cell Lesions.

Tumor-induced osteomalacia (TIO) is a rare cause of hypophosphatemia involving overproduction of fibroblast growth factor 23. TIO has been described largely in adults with small mesenchymal tumors. We report a case of TIO in a child who presented with knee pain and radiographic findings concerning for rickets, and was found to have maxillomandibular giant cell lesions. The patient was treated with oral phosphorus and calcitriol, surgical debulking, and intralesional corticosteroids, which resulted in tumor regression and normalization of serum fibroblast growth factor 23 and phosphorus. This case illustrates the occurrence of this rare paraneoplastic syndrome in children and adds to our knowledge about clinical manifestations and pathologic findings associated with pediatric TIO.

Surgical management of mandibular ameloblastoma and immediate reconstruction with nonvascularized bone graft and hyperbaric oxygen therapy / Tratamiento quirúrgico de ameloblastoma mandibular y la reconstrucción inmediata con injerto oseo libre y terapia con oxígeno hiperbárico

Extensive resection of tumor often results in bone and soft tissue defects that cause functional and esthetic consequences. The reconstructive surgery is extremely important for the rehabilitation of these patients. The purpose of this study is to report on the use of Hyperbaric Oxygen therapy (HBO) in the case of a large ameloblastoma treated with segmental resection and reconstructed immediately with nonvascularized bone graft (NVBGs) from iliac crest. A 41-year-old woman was referred to our department because of paresthesia of the inferior alveolar nerve and history of swelling in the molar and ramus region of the left mandible. Panoramic radiograph depicting well-defined multilocular radiolucency extending from second pre-molar region to the left ramus region. An incisional biopsy confirms the diagnosis of solid ameloblastoma. The treatment of choice was segmental mandibular resection and immediate mandibular reconstruction using NVBGs from iliac crest, followed by removal of internal fixation and placement of dental implants with immediate loading. The patient received preoperative HBO (a 90-min session at 2.2-2.4 atmospheres, five times per week for two weeks, for a total of up to 10 sessions). Postoperative HBO (10 further 90-min sessions) was administered within 2weeks. The patient received rehabilitation with a mandibular implant-supported fixed complete dental prosthesis. The present study showed successful management of mandibular ameloblastoma that associated extensive surgery, immediate reconstruction with NVBGs from iliac crest, hyperbaric oxygen therapy and dental implants. These combined procedures allowed removal of lesion and reestablishment of mandibular contour and function.

La resección extensa de un tumor a menudo da lugar a defectos del hueso y de los tejidos blandos, que causan consecuencias funcionales y estéticas. La cirugía reconstructiva es extremadamente importante para la rehabilitación de estos pacientes. El propósito de este estudio fue informar sobre el uso de la terapia de oxígeno hiperbárico (HBO) en un caso de un ameloblastoma de gran tamaño, tratado con resección segmentaria y reconstruido inmediatamente con injerto óseo no vascularizado (IONV) de la cresta ilíaca. Una mujer de 41 años fue derivada a nuestro servicio por parestesia del nervio alveolar inferior e historia de hinchazón en la región molar y ramina de la mandíbula izquierda. Radiografía panorámica que muestra una radiolucencia multilocular bien definida que se extiende desde la segunda región pre-molar hasta la región de la rama izquierda. Una biopsia incisional confirma el diagnóstico de ameloblastoma sólido. El tratamiento de elección fue la resección mandibular segmentaria y la reconstrucción mandibular inmediata mediante IONV de cresta ilíaca, seguido de la eliminación de la fijación interna y la colocación de implantes dentales con carga inmediata. La paciente recibió OHB preoperatoria (una sesión de 90 minutos a 2.2-2.4 atmósferas, cinco veces por semana durante dos semanas, para un total de hasta 10 sesiones). La OHB postoperatoria (10 sesiones adicionales de 90 minutos) se administró en 2 semanas. La paciente recibió rehabilitación con una prótesis dental fija con implante mandibular. El presente estudio mostró un manejo exitoso del ameloblastoma mandibular asociado a una cirugía extensa, reconstrucción inmediata con IONV de cresta ilíaca, oxigenoterapia hiperbárica e implantes dentales. Estos procedimientos combinados permitieron la extirpación de la lesión y el restablecimiento del contorno y la función mandibular.

Clinicopathological Study of Primary Intraosseous Squamous Cell Carcinoma of the Jaw and a Review of the Literature.

PURPOSE: Primary intraosseous squamous cell carcinoma (PIOSCC) is a rare malignant odontogenic tumor that originates from odontogenic epithelial remnants. It is often difficult to diagnose PIOSCC definitively; hence, extraction or surgical treatment is performed before the initial diagnosis in most cases. The present study examined new insights into and prognostic factors of patients with PIOSCC admitted to the authors' department. MATERIALS AND METHODS: An extensive record review was conducted of patients who underwent radical surgery for PIOSCC from January 2001 through December 2014. RESULTS: Of all cases of OSCC, the frequency of PIOSCC was 1.45%. The 2-year relapse-free survival (RFS) and overall survival (OS) rates were 50.0 and 41.6% in all cases, respectively. Three patients underwent surgery or tooth extraction before the initial diagnosis; in fact, intervention before initial diagnosis was found to be an important poor prognostic factor for RFS and OS. In contrast, patients who were not treated before the initial diagnosis was made did not exhibit any locoregional recurrence. CONCLUSIONS: The treatment of PIOSCC should be similar to that for oral cancer with at least clinical stage T3N0 in the National Comprehensive Cancer Network clinical practice guidelines. In addition, cases of PIOSCC that are not treated before the initial diagnosis are more likely to obtain a good prognosis.

Hermangioma intraóseo: reto diagnóstico. Presentación de un caso y revisión de la literatura / Intraosseous hemangioma: a diagnostic challenge. Report of a case and review of the literature

Los hemangiomas son neoplasias benignas de origen endotelial, formadoras de vasos. Los hemangiomas intraóseos son condiciones raras que comprenden del 0.5 a 1% de todos los tumores intraóseos. Su localización más común es la columna vertebral y los huesos del cráneo. Aquéllos que se presentan en los maxilares son tumores muy raros. Dos tercios de éstos se localizan en la mandíbula, con una proporción de mujer a hombre de 2:1. El objetivo de este artículo es reportar un caso signifi cativo de un hemangioma central de grandes dimensiones de la rama de la mandíbula del lado derecho, el cual fuetratado exitosamente con resección quirúrgica y ligadura de vasos nutricionales. Caso clínico: Paciente de 14 años que presenta un área radiolúcida unilocular en la rama mandibular del lado derecho. Clínicamente se observa aumento de la cara difuso, que causa asimetría facialasintomática de tres años de evolución. Conclusiones: La importancia del hemangioma intraóseo de los maxilares radica en su proximidad con los dientes, lo que representa un alto riesgo de sangrado debido a cualquier traumatismo por intento de extracción. El diagnóstico de hemangioma intraóseo, debido a su baja incidencia e inusual manera de presentación, es un reto diagnóstico...

Combined Mandibular Guidance Therapy in the Management of a Hemimandibulectomy Patient.

This case history report describes two different devices, maxillary ramp prostheses (MRP) and mandibular guide flange prostheses (MGFP), prescribed for managing a hemimandibulectomy patient's deviated mandible. The patient was given muscle reprogramming exercises with coordinated use of both guidance prostheses for 2 months, leading to improvements in both postsurgical mandibular deviation and occlusal equilibration. A successful intercuspal position was eventually accomplished through the use of the combination therapy. MRP and MGFP can be a useful approach to avoid mandibular deviation and compromised function following a partial mandibular resection.

Health-related quality of life after segmental resection of the lateral mandible: Free fibula flap versus plate reconstruction.

OBJECTIVES: Segmental resection of the mandible causes functional, aesthetic and social problems affecting health-related quality of life (HRQoL). It is often assumed that reconstruction with composite free flaps guarantees better function and aesthetics than bridging the defect with reconstruction plates. METHODS: Using the European Organization for Research and Treatment of Cancer questionnaires (EORTC QLQ-C30 version 3.0 and EORTC QLQ-H&N35), we compared HRQoL in patients who received free fibula flaps versus reconstruction plates after segmental resection of the lateral mandible. RESULTS: Thirty-seven completed questionnaires (18 fibula reconstructions and 19 patients with reconstruction plates) were available. Reconstruction with a free fibula flap did not provide clear additional benefit to bridging the defect with a reconstruction plate after segmental resection of the lateral mandible. In particular aspects known to have the most impact on HRQoL like swallowing, speech and chewing were not influenced by the type of reconstruction. CONCLUSIONS: Reconstruction of segmental defects of the lateral mandible with free fibula flap and reconstruction plate resulted in comparable HRQoL. If dental rehabilitation by means of dental implants is not anticipated in the fibula, then plate reconstruction with adequate soft tissue remains a suitable technique for the reconstruction of segmental defects of the lateral mandible.

One-stage treatment to osteochondroma of the coronoid process and secondary facial asymmetry with coronoidectomy and reduction malarplasty: a case report and literature review.

PURPOSE: This study summarizes the literature concerning osteochondroma of the mandibular coronoid process and presents a case of 1-stage treatment for this condition and concomitant facial asymmetry. MATERIALS AND METHODS: A 20-year-old man presented with osteochondroma of the mandibular coronoid process. Radiologic images showed a mushroom-shaped coronoid growth inside the zygomatic arch with outward expansion. Coronoidectomy and reduction malarplasty were performed in 1 stage. The literature on osteochondroma of the mandibular coronoid process since 1943 was reviewed concerning etiology, pathogenesis, clinical characteristics, diagnosis, and treatment. RESULTS: At 20-month follow-up, the patient achieved markedly improved joint function and a symmetric facial appearance after excision of the osteochondroma. CONCLUSION: Coronoidectomy combined with simultaneous reduction malarplasty could be an alternative and promising method to treat osteochondroma of the coronoid process with secondary facial asymmetry.

Multidisciplinary approach to follicular thyroid carcinoma with giant mandibular and multiple sites metastases Case report.

UNLABELLED: Multidisciplinary approach to follicular thyroid carcinoma with giant mandibular and multiple sites metastases. Case report Metastatic tumors generally have poor prognosis, with short survival period and rarely indication to surgical treatment. In case of thyroid-differentiated cancer with distant metastases, prognosis is usually better, because of the possibility of treating metastasis by Radio Ablation by 131Iodine, after surgery. We report the case of a 65 years old woman, presenting with a giant mandibular metastasis from follicular thyroid carcinoma, originating from a cervico-mediastinal nonfunctioning goiter, with lung metastases. After the diagnostic work-up, she underwent left hemi-mandibulectomy, reconstruction by the placement of a precustomized titanium plate with condylar prosthesis and total thyroidectomy. Subsequently the Patient was treated by Radio Ablation by 131 Iodine, in four consecutive sessions. She is alive with no progression of the neoplasm after forty-six months follow-up. Even in advanced differentiated thyroid carcinoma, surgery should be taken into consideration, to treat the patient by complementary therapies and to improve the prognosis in term of survival. KEY WORDS: Advanced differentiated thyroid carcinoma, Metastatic differentiated thyroid carcinoma.

Sarcomas mandibulares: experiencia quirúrgica en los últimos 10 años / Mandibular sarcomas: surgical experience over the past 10 years

Introducción: Los sarcomas mandibulares representan una entidad de difícil estudio por su escasa incidencia e histopatología. Pacientes y métodos: Presentamos la experiencia del servicio de Cirugía Oral y Maxilofacial del Hospital Vall d’Hebron de Barcelona en los últimos 10 años (2001-2010) en el manejo de los sarcomas mandibulares, realizando una revisión retrospectiva de 12 casos de pacientes afectos por este tipo de tumor. Resultados: La técnica más utilizada para la reconstrucción fue el colgajo microvascularizado (hueso peroné: 8/12), recibiendo tratamiento adyuvante (quimioterapia y/o radioterapia) el 82% de los pacientes. Cinco pacientes fallecieron (42%), 2 se encuentran con progresión de la enfermedad (16%) y 5 sobreviven libres de enfermedad (42%) hasta la finalización del seguimiento. Conclusiones: Los casos descritos representan una serie singular debido a la localización mandibular, no antes publicadas en la literatura. Aún así, los resultados obtenidos en términos de supervivencia y factores pronóstico son similares a los descritos para los sarcomas de cabeza y cuello. La consecución de márgenes libres con la cirugía es la clave del tratamiento, siendo necesario el tratamiento complementario para mejorar el pronóstico(AU)

Introduction: Sarcomas located in the mandible are difficult to study due to their relatively rare appearance and histology. Patients and Methods: We present the experience of the Oral and Maxillofacial Surgery Department of the Vall d’Hebron Hospital in Barcelona over the last 10 years (2001-2010) in the management of jaw sarcomas, performing a retrospective review of 12 cases of patients affected by this type of tumour. Results: The technique mostly used for the reconstruction was the microvascularised bone graft (fibula: 8/12), with 82% of the patients receiving adjuvant therapy (chemotherapy and radiotherapy). Five of the patients died (42%), twowere found with disease progression (16%), and 5 survived free of disease (42%) until the end of follow-up. Conclusions: The cases described are a unique series due to the mandibular location. Prognostic factors and survival rates are similar to those described for head and neck sarcomas. Free margin during surgery must be the goal of treatment, additional chemotherapy or radiotherapy or both being required to improve the survival rates(AU)

Multiple osteolytic lesions of intraosseous adenoid cystic carcinoma in the mandible mimicking apical periodontitis.

AIM: Adenoid cystic carcinoma (ACC) is a relatively rare epithelial tumour of the salivary glands in the maxillofacial region. About 40-60% of the patients develop distant metastases, which have been documented most commonly in the lung but also in brain, bone, liver, thyroid, spleen and pancreatic gland. SUMMARY: A 55-year-old women with intraosseous ACC in the mandible mimicking apical periodontitis following curative resection and radiotherapy is presented. Three years later, multiple lung metastases were observed followed by chemotherapy. Five years after curative resection, the patient presented simultaneously with new expansive soft tissue in the pancreas and mammary gland as well as in the kidney found to be metastatic ACC. No case has been reported to date on the manifestation of distant metastases of intraosseous ACC in the breast and the kidney as described by these observations. Metastatic mammary gland ACC stained positive for epithelial growth factor receptor (EGFR) but was negative for HER-2/neu and Cyclooxygenase-2 (COX-2) expression.

Assessment of quality of life after implant-retained prosthetically reconstructed maxillae and mandibles postcancer treatments.

PURPOSE: The aim of this prospective study was to assess treatment outcome and impact on quality of life with implant-retained prosthesis in reconstructed jaws in head and neck cancer patients. MATERIALS AND METHODS: Twelve patients were rehabilitated with implant-retained dental prosthesis following free fibular graft after segmental resection. These subjects were evaluated by standardized questionnaires European Organization for Research and Treatment of Cancer QLQ-C30 (version 3) and clinical assessment for quality of life. Objective assessment of speech parameters was done with Dr. Speech Software (Tiger DRS Inc., Seattle, WA). The questionnaire consisting of information on evaluation of deglutition, salivation, status of the mandible and teeth in relation to predisease level was used for subjective judgment of speech. RESULTS: Consumption of solid, semisolid, and overcooked food was considerably better with the prosthesis. Drinking ability was not affected. Patients' voice resonance was improved, and they could sustain phonation for longer duration without difficulty. They were able to speak loudly, and their intonation pattern was also slightly better. Failure of the implants to osseointegrate at the end of 18 months was observed in 37% of the patients. This was attributed to radiation before implant insertions and periimplantitis. Despite the observed improvement in some patients, the statistical analysis of speech, swallowing parameters, and quality of life were not significant because of the paucity of numbers in this pilot study. There was no improvement in the symptoms scale scores. CONCLUSION: Reconstruction and rehabilitation of the jaws affected by tumor restores the patient anatomically, esthetically, and functionally to optimum levels. However, a study with larger numbers of patients is necessary to ascertain the benefits of this treatment modality.

[Maxilla-mandibular brown tumors as a first sign of parathyroid adenoma]. / Tumeurs brunes maxillomandibulaires révélant un adénome parathyroïdien.

OBJECTIVES: Through a novel observation of parathyroid adenoma revealed by brown tumors of the jaws and a review of the literature, the authors describe this rare mode of primary hyperparathyroidism discovery. MATERIAL AND METHODS: The patient was a 23-year-old woman who consulted for a recurrent tumefaction of the maxillary; histology showed reparative giant cell granuloma. RESULTS: The clinical examination found an osseous tumefaction in continuity with the zygomatic bone and a gingival tumefaction on the mandible symphysis. The radiological findings showed two osteophytic lesions: mandibular and maxillary. The phosphocalcic metabolism was disturbed and the parathormone rate was high. The etiologic search consisted of a MRI of the neck, which showed a mass behind the thyroid gland, suggesting a parathyroid adenoma. The diagnosis was confirmed at surgical exploration. After removal of this tumor, the blood calcium rate dropped sharply and the bone tumefaction progressively regressed. CONCLUSION: Brown tumors are a rare mode of parathyroid adenoma discovery, and the jaw location is exceptional. The diagnosis is based on the parathormone rate, and radiological exams generally find the etiology. Treatment is based on surgery of the parathyroid adenoma.

The managements of orofacial tumors of children in Iraq.

These studies were carried out in the maxillofacial unit, surgical specialties hospital, medical city, Baghdad, included 55 patients with orofacial tumors; their ages ranged from 2 days to 14 years (mean, 7 years). Twenty-eight of them were girls, and 27 were boys. Tumors included 20 cases of benign tumors and 35 cases malignant. Treatment modalities ranged from complete surgical excision, surgical shaving operations, and deep x-ray therapy (DXT; radiotherapy) for some benign tumors. The management of malignant tumors was carried out by the use of chemotherapy, chemotherapy and DXT to radical surgery, or radical surgery with DXT. Reconstruction of the mandible was carried out using a rib graft or a block of a corticocancellous bone graft from the iliac crest with reimplantation of the condyle after resection from the tumor and fixed by rigid fixation to the bone graft. Temporary reconstruction of the mandible done by Kirschner wire for malignant tumors required a postsurgical DXT. A temporalis muscle flap was used for the augmentation of the orbit with a frontoorbital flap after radical excision of a malignant tumor of the orbit, and a silastic implant (silicon rubber) was used for reconstruction of the orbital floor. A long-term follow-up ranged from 2 to 15 years. The aim of this study was to present a certain number of cases with an interesting pathologic tumor condition showing peculiar behaviors; the management of these cases was a challenge to our surgical experience.

Palliative care for patients with head and neck cancer: "I would like a quick return to a normal lifestyle".

Head and neck cancers constitute a diverse group of diseases including malignancies of the oral cavity, oropharynx, larynx, sinuses, and skull base. Treatment of these cancers includes a combination of surgical resection, chemotherapy, and radiation. Due to both the patterns of disease recurrence and the adverse effects of treatments, patients with head and neck cancer often have a complex and prolonged course of illness that is marked by periods of freedom from disease and symptoms interspersed with bouts of serious illness, debility, and numerous physical and psychological symptoms including pain, dysphagia, weight loss, disfigurement, depression, and xerostomia. Thus, management of this disease is best provided by an interdisciplinary team that includes individuals from the disciplines of otolaryngology, palliative care, radiation oncology, oncology, nutrition, speech, and physical and occupational therapy. Using the case of Mr K, we describe the symptoms encountered by patients with head and neck cancer and suggest options for management. We discuss the psychological aspects that affect these patients, including issues such as changes in body image, quality of life, anxiety, and guilt. Finally, we discuss the importance of the interdisciplinary team in the care of these patients and outline the roles of each team member. By providing comprehensive care to patients with malignancies of the head and neck, clinicians can increase the likelihood that patients and their families will be able to obtain the best possible outcomes and quality of life.

Adjuvant antiangiogenic therapy for giant cell tumors of the jaws.

PURPOSE: To further evaluate a novel treatment protocol for the management of aggressive giant cell lesions (GCLs) consisting of enucleation followed by adjuvant subcutaneous interferon alpha therapy. PATIENTS AND METHODS: Using a retrospective case series study design, a sample of patients with aggressive GCLs was enrolled between April 1995 and June 2006. Lesions were enucleated with preservation of vital structures. Postoperatively, the patients received daily subcutaneous interferon alpha (3 million units/m2 of body surface area). Interferon treatment continued with regular clinical and radiographic follow-up until the surgical defects filled in with bone, as demonstrated by panoramic radiographs and confirmed by computed tomography. Side effects, such as fever, fatigue, weight loss, decreased white blood cell count, decreased platelet count and elevated liver enzymes, were monitored. After completion of interferon therapy, patients followed for 2 years without evidence of recurrence were considered cured of disease. RESULTS: The study sample was comprised of 26 subjects (65% female) with a mean age of 18.5 years. At the time of this writing, 16 of the subjects have completed the protocol and are cured of disease, 6 are in remission, and 4 are in active treatment. Four subjects experienced significant side effects from the interferon, requiring modification of treatment. CONCLUSIONS: Enucleation of aggressive GCLs with preservation of vital structures and adjuvant interferon is an excellent strategy for managing aggressive GCLs. Approximately 15% of subjects developed significant side effects limiting interferon administration and necessitating alternative therapies.

Callusmassage. A new treatment modality for non-unions of the irradiated mandible.

Recent reports on orthopaedic surgery focus on mechanical stimulation of the regenerate during distraction therapy of non-unions in long-bone-surgery. In the field of maxillofacial surgery, callus stimulating techniques are rarely reported. The case of a 65-year-old man with a radiogenic mandibular non-union after ablative tumour therapy and pre-operative radiation therapy presented with a non-union. Vertical distraction in combination with subsequent repeated, stepwise compression and distraction (=massage) had a positive effect on the consolidation of the regenerate.

Serendipitous diagnosis of protein S deficiency.

A 46-year-old male sought periodontal care for a swelling on his right mandibular gingiva. An excisional biopsy revealed a well-differentiated squamous cell carcinoma. Surgical treatment consisted of a right segmental mandibulectomy with ipsilateral right neck dissection and fibular free flap reconstruction. Two days after the surgical procedure, a weakened Doppler signal suggested vascular compromise of the graft. The patient was returned to the operating room where complete thrombosis of the internal jugular vein (recipient vessel) was observed. This event prompted a complete hematological evaluation that disclosed low serum levels of protein S. The patient was started on systemic heparin and local medicinal leeches. A week later, systemic warfarin sodium was added and successfully resolved the vascular compromise of the graft. Two years later, the patient is active and lives a full life with occasional adjustments of warfarin sodium. This case represents the first report on the treatment of gingival carcinoma that led to the serendipitous discovery of an unrelated and unusual systemic condition, protein S deficiency.