Adjuvant Alendronic Acid in the Management of Severe Cherubism: A Case Report and Literature Review.

Cherubism is a rare disease of the jaws characterized by bilateral symmetrical painless expansion of the mandible and maxilla. In extreme cases, larger lesions can become exophytic and have profound functional and esthetic implications. Several pharmacologic agents have been trialed in the treatment of cherubism with variable success reported. Bisphosphonates have not been significantly studied in this setting. We present a case where oral alendronic acid was used as an adjuvant treatment after surgical debulking of the maxilla in a 13-year-old boy with a severe case of cherubism.

Primary Extranodal Non-Hodgkin Lymphoma in the Infra-Orbital Region ­ A Diagnostic Challenge.

Lymphomas within the head and neck region (HNR) are relatively uncommon; however, they can mimic common odontogenic conditions leading to diagnostic delays and subsequently the implementation of treatment. We report a case of a chronic infra-orbital swelling which, following excision, was diagnosed as an extranodal low grade Non-Hodgkin lymphoma. This paper explains the mode of presentation of extranodal lymphomas in the HNR, so that dental practitioners may consider it as a potential diagnosis when presented with a lump in the HNR. Clinical relevance: Extranodal lymphomas presenting within the head and neck region can have a multitude of clinical presentations, which may often resemble odontogenic conditions. This can cause confusion, resulting in diagnostic delays and treatment. This case highlights the importance of being aware of the features of extranodal lymphoma in the head and neck region, and the diagnostic challenges that may be encountered.

Mutation detection in saliva from oral cancer patients.

OBJECTIVES: The incidence of head and neck squamous cell carcinoma (HNSCC) continues to increase and although advances have been made in treatment, it still has a poor overall survival with local relapse being common. Conventional imaging methods are not efficient at detecting recurrence at an early stage when still potentially curable. The aim of this study was to test the feasibility of using saliva to detect the presence of oral squamous cell carcinoma (OSCC) and to provide additional evidence for the potential of this approach. MATERIALS AND METHODS: Fresh tumor, whole blood and saliva were collected from patients with OSCC before treatment. Whole exome sequencing (WES) or gene panel sequencing of tumor DNA was performed to identify somatic mutations in tumors and to select genes for performing gene panel sequencing on saliva samples. RESULTS: The most commonly mutated genes identified in primary tumors by DNA sequencing were TP53 and FAT1. Gene panel sequencing of paired saliva samples detected tumor derived mutations in 9 of 11 (82%) patients. The mean variant allele frequency for the mutations detected in saliva was 0.025 (range 0.004 - 0.061). CONCLUSION: Somatic tumor mutations can be detected in saliva with high frequency in OSCC irrespective of site or stage of disease using a limited panel of genes. This work provides additional evidence for the suitability of using saliva as liquid biopsy in OSCC and has the potential to improve early detection of recurrence in OSCC. Trials are currently underway comparing this approach to standard imaging techniques.

To retrieve or not to retrieve the coronectomy root--the clinical dilemma.

UNLABELLED: Coronectomy of mandibular third molars is a well established technique that is going through a resurgence as it seems to reduce the risk of inferior dental nerve (IDN) injury. The reservation with the technique arises because of fear that the retained root will become infected and symptomatic over time. General dental practitioners will be responsible for the long-term review and care of these patients and, consequently, it is important that they are aware of the technique and its sequelae. CLINICAL RELEVANCE: Coronectomy of mandibular third molars to avoid nerve injury is becoming increasingly popular. It is important that general dental practitioners (GDPs) are aware of the immediate and later sequelae of treatment and the implication of the retained root.

Simultaneous and differential fronto-orbital and midface distraction osteogenesis for syndromic craniosynostosis using rigid external distractor II.

In syndromic craniosynostosis, the relation between the supraorbital area and the frontal bone is not good, and it is not possible to reform this area with 1-block advancement. To avoid this problem, the frontal bone is separated from the fronto-orbital bandeau, each is reshaped and remodeled separately, and then both are reattached. The retrusion of the midface, especially in syndromic craniosynostosis, is usually greater than that of cranial bones, so the technique usually separating the midface from the cranium is Le Fort III osteotomy, which allows differential distraction of each part. In this procedure, the cranial and midfacial bones are advanced simultaneously and differentially, both to the planned extent, in a single-stage operation, using rigid external distractor II, correcting exorbitism, respiratory embarrassment, and cranial structures and avoiding eye complications in the future. This procedure was used, with a follow-up, in 10 patients with syndromic craniosynostosis from 2 to 5 years.

The use of mixed reality in dentistry.

Augmented reality (AR) was first described in the literature in the 1990s. It has been shown as a futuristic concept in television, film and media, and now in the twenty-first century has become a reality. AR is defined as an interactive experience of a real-world environment where the object that resides in the real world is enhanced by computer-generated perceptual information.Microsoft HoloLens is a mixed reality device which has the capability to provide a real-time, three-dimensional platform using multiple sensors and holographic processing to display information and even simulate a virtual world. With rapidly evolving technology and virtual learning on the increase, the HoloLens technology can be used as a vital tool for dental education and surgical planning. However, within dentistry at present, there is limited research regarding its benefits and potential.The authors would like to demonstrate the use of HoloLens in three common oral surgery procedures and how it can be used to distinguish anatomy and benefit surgical planning, aid in patient communication and play a role in dental education.

Transoral removal of hiloparenchymal submandibular calculi: a long-term clinical experience.

Traditional management of hiloparenchymal submandibular calculi is based on sialadenectomy. Recently, different minimally invasive and conservative techniques have been developed for the treatment of the submandibular calculi. We aimed to investigate the effectiveness of transoral surgical removal of large hiloparenchymal calculi by monitoring the trend for recurrence with clinical and ultrasonographic follow-up. A consecutive series of 84 patients with large (>7 mm) hilar or hiloparenchymal submandibular calculi underwent the transoral surgical removal under general anaesthesia. A video-assisted endoscopic procedure was performed in eight patients. All the patients underwent diagnostic ultrasonography and colour Doppler ultrasonography and clinical evaluation to define the exact location (hilar vs. parenchymal) and the diameter of the stone. The surgical procedure was successful in all but one of the patients. Stone recurrence was observed in 16 patients but obstructive symptoms were observed in only 12 patients during a median follow-up time of 52 months. The risk for recurrence was higher in patients who previously underwent extracorporeal shockwave lithotripsy. Conservative transoral removal of large hiloparenchymal submandibular calculi is a safe and effective surgical procedure. Future studies with longer follow-up will confirm the risk for recurrence of calculi.

Dentoalveolar radiation dose following IMRT in oropharyngeal cancer-An observational study.

OBJECTIVES: This observational study aims to determine individual dental doses in oropharyngeal cancer (OPC) patients managed by intensity modulated radiation treatment (IMRT). MATERIALS AND METHODS: OPC patients treated with IMRT had each tooth individually contoured on post-IMRT CT scans. The mean, maximum and minimum doses were calculated per tooth-based upon patient and tumor demographics (tumor size and nodal status). RESULTS: A total of 160 patients were included in this study. Escalating tumor size and nodal status led to an observed increase in Dmean doses to the dentition on the contralateral tumor side. A significant region in both jaws received >30 Gy in this tumor group. CONCLUSION: Tumor demographics were observed to influence RT doses to the dentition and need to be considered when providing a pre-RT dental assessment. The observed dose of >30 Gy in large spans of the dentition and jaws highlights future risk of dental deterioration and ORN with long term survival.

Pre-radiotherapy dental status of oropharyngeal cancer patients based on HPV status in a novel radiation era.

Objectives Among common head and neck cancers (HNCs), oropharyngeal cancer (OPC) patients have been identified as having a better dentition than many other tumour subsites. OPC consists of human papillomavirus (HPV)-positive and negative groups with different prognosis. The purpose of this study is to explore the presenting dental status of OPC patients based on HPV status at the pre-radiotherapy phase.Materials and methods The study reviewed the dental panoramic radiographs of OPC patients seen at a dedicated pre-radiotherapy dental assessment clinic from 2011-2017. Only patients planned for intensity-modulated radiotherapy treatment were included within this study. Relevant dental and oncological data were collected.Results A total of 316 patients with known HPV status (215 positive; 101 negative) were included for analysis. HPV-positive patients had significantly more teeth on attendance than HPV-negative patients (22.3 vs 19.0, p = 0.0000) and horizontal bone loss was less severe compared to HPV-negative patients (p = 0.0000). HPV-positive males and patients in the 55-64 decade presented with the best and most complex dentition.Conclusion The rise of OPC with the prospect of long survival, particularly in HPV-positive patients, requires a dentition with adequate function and subsequent maintenance. The current study demonstrated that these patients have a complex dentition presenting new challenges to the dentist. This may explain in part the elevated osteoradionecrosis rate seen in this tumour group.

Presenting pre-radiotherapy dental status of head and neck cancer patients in the novel radiation era.

Objectives Dental assessment remains a key intervention for head and neck cancer (HNC) patients pre-radiotherapy (RT). The purpose of this study was to identify the variation in dental status of patients pre-treatment, with respect to population and oncological demographics.Materials and methods The study reviewed dental panoramic radiographs of HNC patients seen on a dedicated pre-RT dental clinic from 2011-2017. Only patients who had undergone intensity-modulated radiotherapy treatment were included within this study. Relevant dental and oncological data were collected.Results A total of 886 patients were included in this study, with oropharyngeal cancer constituting 36% of the cohort. The average number of teeth in HNC patients was <21 at the pre-RT phase, which is below the recognised threshold for a functional dentition. Smoking status has a significant impact on overall DMFT (decay/missing/filled teeth), severity of horizontal bone loss and the number of third molars present (p <0.001). In the latter, males had a higher mean number of third molars compared to females (p <0.005). Comparing dental status of patients based on their tumour sub-site identified significant (p <0.0005) variation in all aforementioned categories.Conclusion There are distinct differences in the dental health of HNC patients due to commence RT, compared to the general population. It varies by cancer sub-site and this should be taken into consideration at dental assessment to tailor a dental care plan to the needs of the individual. Consideration should be given to balancing masticatory function against the risks of osteoradionecrosis on the background of increasingly extended survivorship.

Twenty-Five Years of Experience with the Submental Flap in Facial Reconstruction: Evolution and Technical Refinements following 311 Cases in Europe and Africa.

BACKGROUND: The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author's (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa. METHODS: This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered. RESULTS: The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent). CONCLUSIONS: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Conservative treatment of oral ranula by excision with minimal excision of the sublingual gland: histological support for a traumatic etiology.

PURPOSE: This study investigates, clinically and histologically, a new conservative technique for the treatment of oral ranula based on the premise that a discrete unit of the sublingual gland feeds the ranula, which can therefore be treated by local removal with the attached part of the sublingual gland. PATIENTS AND METHODS: The study group consisted of 8 patients with ranula treated by decompression of the ranula followed by local surgical removal together with the attached part of the sublingual gland. Detailed histologic examination of the entire specimen was undertaken in every case. RESULTS: The treatment was successful in all the patients and there have been no recurrences after reviews of from 13 to 29 months (median, 26 months). Histologic examination of the entire specimen showed communication between the removed part of the sublingual gland and the ranula by way of a torn duct in every case. CONCLUSIONS: The premise that the ranula is fed by an attached, discrete unit of the sublingual gland has been vindicated and is the basis for the successful conservative treatment of ranula by decompression and local surgical removal together with the attached part of the sublingual gland. The finding of communication between the attached sublingual gland and ranula in every case indicates a traumatic etiology for these ranulas.

Atypical fulminating dental nfections.

UNLABELLED: Dental surgeons are faced with treating dental infections on a daily basis and the cases discussed in this paper highlight the potential outcome of such infections, especially in immunocompromised patients. Fulminating infection in the head and neck may present as a rapidly progressive, potentially fatal condition characterized by extensive necrosis of the subcutaneous tissues. One form of such infection is necrotizing fasciitis. Although first described in 1793 by Pouteau, the term necrotizing fasciitis was first coined in 1952 by Wilson who noted that facial necrosis was the most consistent feature of this disease. When necrotizing fasciitis occurs in the head and neck region it is usually odontogenic in origin. This paper reviews the cases of four patients presenting with atypical fulminating dental infection who presented to the oral and maxillofacial department at Guy's and St Thomas's Hospital, London, resulting in cellulitis and necrotizing fasciitis. Aggressive management is critical for patient survival and time wasted is tissue lost. CLINICAL RELEVANCE: Early diagnosis and aggressive treatment of dental infections, especially in patients with altered immune status, is critical. There should be a high index of suspicion in patients with dental infections not responding to treatment and maxillary dental infections with sinus symptoms.

The process of symptom appraisal: cognitive and emotional responses to detecting potentially malignant oral symptoms.

OBJECTIVE: Following the self-discovery of symptoms of oral cancer, approximately 30% of patients wait for more than 3 months before seeking attention from a health care professional. Although symptom appraisal is known to be an important stage in the decision to seek help, little is known about the process of symptom appraisal. The aims of the current study were to produce a theory-guided investigation of the specific cognitive interpretations and emotional reactions to the self-discovery of potentially malignant oral symptoms and to gain understanding as to why these may change prior to help seeking. METHODS: In-depth semi-structured interviews were conducted with 57 consecutive patients who had been referred with potentially malignant oral symptoms. Participants were asked about symptom detection, initial and subsequent beliefs about symptoms, and emotional responses prior to their first visit to a health care professional. The tape-recorded interviews were transcribed verbatim and analyzed using "framework analysis." RESULTS: Patients often attributed the symptoms to transient, minor conditions such as mouth ulcers, physical trauma, or dental problems and, in turn were unconcerned about their presence. Patients infrequently attributed their symptoms to cancer. Origins of specific interpretations included previous experiences, specific symptomatology, logical associations with the perceived cause, and information from medical literature. Stimuli for reinterpretation included receipt of new information, symptom development, and persistence of symptoms. CONCLUSION: This study has documented the process of symptom appraisal and indicates that an individual's interpretation of potentially malignant oral symptoms is often misguided.

A revolution in the management of obstructive salivary gland disease.

UNLABELLED: Salivary gland obstruction is the commonest cause of salivary gland disease presenting to the general dental practitioner. To date, with the exception of the most surgically accessible stones found within the anterior ducts, there has been little treatment to offer patients except surgical removal of the gland, with the associated risks to the facial and trigeminal nerves. In the last 10 years, more conservative treatment modalities have been developed, opening up a range of treatment options which combine to provide an alternative management of these cases. This paper presents data from one unit in which lithotripsy, which is the destruction of stones (calculi) using shock waves, basket retrieval, a modified minor surgical technique, and balloon dilatation have been used to treat salivary gland obstruction successfully. Over 70% of stones can now be retrieved leaving a functioning gland. CLINICAL RELEVANCE: Salivary gland obstruction is a clinical problem presenting to the general dental practitioner, and requires an understanding of the range of treatment options available.

Argument for the conservative management of mandibular ameloblastomas.

Ameloblastoma is a rare, benign, odontogenic tumour that affects the mandible more commonly than the maxilla. Solid or multicytic variants are often resected and the defects reconstructed with a free flap. To establish the outcome after enucleation and application of Carnoy's solution, irrespective of histological subtype, we used the hospital's histology database to identify all the patients treated between 2001 and 2014 by one surgeon. Variables included patients' characteristics, histological subtype, radiological appearance, follow-up period, and incidence of recurrence. A total of 27 patients (13 male) were included, mean age 41 years (range 12-79). Fifteen (56%) had solid multicystic lesions, and there was an overall predominance of the follicular or plexiform variant, or both. Of the 23 preoperative radiographs that were available, 17 lesions were unicystic, 5 multilobular and scalloped with no septa, and one had aggressive features of multilocularity and a poorly defined peripheral margin. The mean duration of follow up was 38 months (range 3-156). Three patients had recurrence at 20, 27, and 35 months postoperatively, and each had repeat enucleation and application of Carnoy's solution. Reconstruction was not necessary, and to date none has recurred. This study shows the potential benefits of conservative surgery and sterilisation of the cystic cavity with Carnoy's solution. Recurrence is low, and with vigilant surveillance, similar repeat procedures have been effective when necessary. A longer follow-up period and larger numbers of patients are now needed to corroborate these findings.

Prophylactic use of pentoxifylline and tocopherol in patients who require dental extractions after radiotherapy for cancer of the head and neck.

Osteoradionecrosis (ORN) is a complication seen intermittently in patients who have had radiotherapy to the head and neck, and results of treatment with pentoxifylline and tocopherol (PVe) have been encouraging. As a consequence, some argue that this should be used prophylactically to lower the risk of ORN after dental extractions in this group. We retrospectively analysed data on 390 dental extractions in 82 patients who had had radiotherapy for cancer of the head and neck. Each had been given PVe prophylactically. Only one patient (1.2%) developed ORN (rate/tooth 0.26%). Patients had taken PVe for a mean (SD) of 11 (23) weeks preoperatively and 13.6 (18) weeks postoperatively. The incidence we found was lower than that normally associated with dental extractions in irradiated patients (7%).

Osteoradionecrosis following treatment for head and neck cancer and the effect of radiotherapy dosimetry: the Guy's and St Thomas' Head and Neck Cancer Unit experience.

OBJECTIVES: To analyze clinical features, dosimetric parameters, and outcomes of osteoradionecrosis (ORN). STUDY DESIGN: Thirty-six patients with ORN who had been previously treated with radiotherapy (RT) were retrospectively identified between January 2009 and April 2014. ORN volumes were contoured on planning computed tomography (CT) scans. Near maximum dose (D2%), minimum dose (Dmin), mean dose (Dmean), and percentage of bone volume receiving 50 Gy (V50) were examined. Clinical and dosimetric variables were considered to compare ORN resolution versus ORN persistence. RESULTS: Median interval time from end of RT to development of ORN was 6 months. Of the ORN cases, 61% were located in the mandible. Dmean to affected bone was 57.6 Gy, and 44% had a D2% 65 Gy or greater. Smoking was associated with ORN persistence on univariate analysis, but no factors were found to impact ORN resolution or progression on logistic regression. CONCLUSIONS: Prevention strategies for ORN development should be prioritized. Dose-volume parameters could have a role in preventing ORN.