Central giant cell granuloma of the jaws-long-term clinical and radiological outcomes of surgical and pharmacological management.

OBJECTIVES: To compare long-term results of different treatment modalities in central giant cell granuloma of the maxillofacial-skeleton. Primary resection may result in major defects. Alternative treatments include pharmacological agents. As yet there has been no consensus on the use of the variety of treatment options, and few studies have reported clarifying long-term results. MATERIALS AND METHODS: This retrospective study on 22 patients with 25 lesions evaluated clinical, radiological and histological features, treatment preformed and lesion recurrence. Success was defined as regression/calcification and failure as recurrence, progression or un-responsiveness. RESULTS: Of the presenting patients, 77% were under age 40. Lesion prevalence was higher in the anterior mandible and left posterior maxilla. Most cases exhibited pain, tooth-mobility or mucosal-expansion. The appearance was predominantly unilocular in the maxilla and multilocular in the mandible, which also exhibited higher prevalence of cortical perforation. Up to 80% of lesions were classified as aggressive. Intralesional steroids/calcitonin were used in 7 cases. Mean follow-up was 39.8 months. Two cases showed recurrence. In 71% of the cases treated pharmacologically, calcification/regression were observed. CONCLUSIONS: Our analysis indicates better outcomes using a combined approach, including both pharmacological and surgical treatments in large aggressive lesions. Pharmacological treatment resulted in decreased size or well-defined lesions, thus reducing the need for extensive bone resection. Dual treatment with corticosteroids and calcitonin showed no superior outcomes, but a larger cohort should be assessed. CLINICAL RELEVANCE: There are several protocols for treatment of central-giant-cell-granuloma lesions, but most are not fully established. It is important to report results that contribute to the establishment of proven protocols. This report attempts to establish the relevance of the combined approach: pharmacological treatment followed by surgical resection.

Is Open Reduction Internal Fixation Using Titanium Plates in the Mandible as Successful as We Think?

ABSTRACT: Titanium plats are the gold-standard for fracture fixation. Titanium is considered biocompatible, corrosion resistant with an elasticity-modulus closest to bone. Nonetheless, titanium plates are not always as inherent as hoped. The authors investigated morbidity associated with titanium plates in mandibular fractures. A retrospective study of mandibular fractures treated between 2000 and 2018 using internal-fixation was conducted. Data included age, gender, complications, and location. Predictor-variable was location. Outcome-variable was plate removal. A total of 571 patients were included, 107 resulted in plate removal (18.7%). Body was the most prevalent location of fracture (29.3%). Symphysis/para-sym-physis showed the highest removal rate (24.1%), followed by body and angle (21.3/19.8%). A total of 23.4% of double-plating cases resulted in plate removal, upper-border in 15% and lower-border in 8.8%, all reconstruction-plates. Exposure was the most frequent complication leading to removal. Although titanium plates are the gold standard, almost every fifth patient returns for plate removal. Age-distribution emphasizing 41 to 50 with decrease towards extremities may imply better healing in the young and soft-tissue elasticity and less complaints in the elderly. Significantly more complications in double-plating compared to lower border suggests proximity to the oral-cavity as a risk-factor for removal. Complication rates and patterns are not negligible and perhaps should encourage clinicians to consider using biodegradable-systems for upper-border plates.

Postextraction Mucormycosis in Immunocompromised-Patient Management and Review of Literature.

PURPOSE: Mucormycosis is an uncommon aggressive, opportunistic infection that can produce widespread orofacial tissue necrosis. This primarily affects immunocompromised individuals. It is the deadliest and most rapidly progressing type of human-affecting fungal infection. The aim of the study is to investigate the diagnostic criteria and treatment approach in 10 cases of mucormycosis in the author's institute from 2008 to 2019. Moreover, a review of the English literature presents all cases of mucormycosis after tooth extraction. MATERIALS AND METHODS: Ten patients at our institute have been treated. They were evaluated and discussed as per their diagnostic criteria, surgical treatment, and mortality rates. RESULTS: All 10 immunocompromised patients had a primary hematologic malignancy. The criteria for a positive diagnosis were clinical symptoms and a biopsy for microbiological culture and histologic analysis. Each patient was subjected to vigorous surgical resection and underwent antifungal treatment. Seven patients died because of their main disease. Owing to the unregulated spread of mucormycosis, 2 patients died. Four cases were diagnosed after maxillary tooth extraction. CONCLUSIONS: The most important factor for patient survival tends to be the management of the underlying disease with early detection and active surgical and antifungal action. Four of 10 cases diagnosed with mucormycosis appeared after tooth extraction, a relatively high number compared with the literature. Therefore, it is the dental profession's obligation to be familiar with the possibility of the potentially severe and possibly fatal complication.

Craniofacial Morphometric Features Associated With Pericondylar Fractures of the Mandible.

The research aimed at investigating potential correlations between craniofacial morphological measurements and mandibular pericondylar fractures, based on a retrospective study of 380 mandible fractures treated in our department, during 2010 to 2017. Predictors included morphological measurements and features. Primary outcome was presence of pericondylar fracture; 133 pericondylar fractures were found, including subcondylar, condylar neck, and condylar head fractures. Condylar neck fractures showed negative correlations with condylar neck width (5.7 mm versus 6.7 mm sagittaly, and 6.1 mm versus 6.8 mm coronally, respectively). Gonial angle (117.3 degrees versus 128.7), and mandibular length 106.2 mm versus 110.4 mm, respectively) showed negative correlation with all pericondylar fractures. Ramus height correlated positively with pericondylar fractures (53.6 mm versus 51.2 mm, respectively). Thus, our results showed condylar neck width was a predictor for condylar neck fractures. In addition, individuals suffering from pericondylar fractures had significantly smaller gonial angles, longer ramus height, and shorter mandibular length. These morphologic features are characteristic of individuals with decreased anterior facial height. Our results corroborated a previous study we had conducted, which suggested that increased anterior vertical growth correlates with angle fractures.

Comparison of patient specific implant reconstruction vs conventional titanium mesh reconstruction of orbital fractures using a novel method.

To compare the reconstruction of orbital fractures using patient-specific implants (PSI) and conventional pre-formed titanium mesh; to develop a method of three-dimensional (3D) superimposition and analysis of the reconstructed orbits; and to present the pitfalls in 3D planning of orbital PSI and how to avoid them. This was a retrospective study of patients with orbital fractures who were treated in our institution between the years 2022 and 2023 using PSI or conservative prefabricated titanium mesh. Three different methods for virtual reconstruction of orbital fractures were used and are detailed with advantages, disadvantages and indications. Data acquired included age, gender, method of reconstruction, functional outcomes and aesthetic outcomes. 3D analysis for accuracy of reconstruction was performed. A total of 23 patients were included; 12 were treated using PSI and 11 using prefabricated titanium meshes. There were 8 male and 4 female patients in the PSI group comparted to 5 and 6 in the prefabricated group. All three virtual methods for reconstruction were used successfully, each with the proper indications. When comparing PSI reconstruction to conventional mesh, a significant difference in accuracy was observed; PSI cases showed an inaccuracy of 0.58 mm compared to 1.54 mm with the conventional method. Complications are presented, and tips for avoiding them are detailed. Three different methods for virtual reconstruction were used successfully; automated computerized reconstruction is used for small defects, repositioning is the superior method for non-comminuted cases while mirroring is the method of choice in comminuted fractures. 3D analysis can be performed using a novel method detailed in this report. PSI reconstruction showed superior results, indicating it should be the method of choice when possible. Pitfalls are presented and approaches to prevent them are discussed. Orbital reconstruction is a very important entity in maxillofacial surgery with crucial functional and esthetical implications, and one should use virtual planning and PSI implants, as they significantly improve outcomes.

Real-time Reconstruction of Comminuted Mandibular Fractures Using 3D Printing.

Background: Comminuted fractures of the jaws are complex injuries requiring special attention. In the past, treatment included closed reduction using maxillomandibular fixation. With advancements in technology and fixation systems, open reduction became a prevalent option. These fractures are difficult to reconstruct during the primary treatment phase, thus resulting in higher complication rates. The introduction of three-dimensional (3D) planning and printing brought about superior outcomes, yet these focus on secondary reconstruction due to the need for outsourcing planning and titanium printing. Methods: In this report, we describe real-time in-house 3D planning and printing using computer-assisted design software and a 3D-fused deposition printer for virtual reduction of the comminuted fractures and printing of the reconstructed mandible. Results: Following virtual 3D reduction, the newly created mandibles were 3D printed. The model was then used to preband a reconstruction plate, which in turn was used as a template during surgery for reducing the segments. The process of virtual reduction and printing should take a couple of hours at most. The results of five cases showed good alignment and proper function. Conclusion: Three-dimensional technology can be applied in the everyday primary care treatment protocol of comminuted fractures as an in-house tool which greatly improves both functional and aesthetic outcomes.

Treatment of Facial Asymmetry Using Distraction Osteogenesis in a Mandible First Approach.

Background: Facial asymmetry includes several etiologies, among them trauma to the condylar area during early childhood and congenital malformations such as hemifacial microsomia. This article describes the management of facial asymmetry in adolescents and young adults using a mandible first approach by distraction osteogenesis, followed by maxillary Le-Fort I as a second stage. Methods: Eighteen patients 14-25 years of age presented with unilateral hypoplasia of the jaws which manifested clinically by deviation of the chin and canting of the occlusal plane. Etiology included hemifacial microsomia and trauma injuries at early childhood.All patients underwent orthodontic treatment and two phases of surgical treatment. Surgical treatment included unilateral mandibular distraction followed by Le-Fort I osteotomy for alignment of the maxilla. Additional bone graft in the affected side and sliding genioplasty were done as required. Results: Marked ramal elongation of 18.94 mm concomitant with mandibular forward traction of 12.5 mm was noted while achieving symmetry. In all cases, the maxilla was centered to the midline in proper occlusion. Post distraction, posteroanterior cephalometric radiographs demonstrated elongation of the affected ramus, improvement in facial symmetry, and correction of the occlusal canting. Relapse was minimal based on long-term follow-ups of 47.4 months. Conclusions: The two-stage surgical approach that includes elongation of the mandible as a first stage followed by adaptation of the maxilla is useful in correcting facial asymmetry. Using this protocol at the correct age (14-18) is very stable, as demonstrated by our results, yet one should always remember the transverse deficiency in the gonial angle requires additional bone grafting or patient specific implants.

Patient-specific Implants for Treating Atrophic Mandibles.

Extremely atrophic mandibles are difficult to treat. Most patients choose to live with removable dentures. However, what if the atrophy is so extreme that spontaneous fractures occur? The objective of this report is to offer a single-stage augmentation method, which uses patient-specific crib-shaped implants (PSI) combined with autogenous free bone grafts. PSI were planned using three-dimensional (3D) segmentation and 3D virtual-planning software. Implants were designed according to the patient's mandible with a mesh-like structure and included large holes for allowing blood supply recovery. During surgery, the PSI fitted perfectly. In cases exhibiting malposition of the mandibular fragments, repositioning was performed using 3D virtual planning. When repositioning mandibular segments, the PSI served as a guide for the correct positioning. Iliac-crest bone graft was harvested and fixed as an onlay over the residual mandibular basal bone. External approach was used to avoid contamination. Six months following surgery, fixation wires were removed, and dental implants were positioned in the newly formed bone. The PSI allowed for rigid fixation, thus leading to optimal incorporation of the iliac-crest bone graft. No further augmentation was required. Bony continuity for future stability and secession of the spontaneous fractures was achieved. Dental implants were placed effortlessly. Treating extremely atrophic mandibles is an entity of its own and is considered one of the most challenging in craniofacial reconstruction. It mostly requires multiple operations with high rates of failure. We offer a novel method of 3D mandibular reconstruction, both vertically and horizontally, showing promising results and achieving enough bone for further dental rehabilitation.

A life-threatening floor of the mouth hematoma secondary to explantation attempt in the anterior mandible.

Implant dentistry is considered to be a safe and routine surgical procedure. However, cases of life-threatening hematoma of the floor of the mouth resulting in airway obstruction were previously reported as a complication of implant placement in the anterior mandible. Massive bleeding in this anatomical site may be caused by perforating the lingual cortex and/or damaging the lingual perimandibular vessels. In the long term, dental implants can fail, mainly due to peri-implantitis, and must be removed. Explantation procedure may occasionally become a complex challenge, with a risk for various complications.
Case report: This report presents the first case of life-threatening hematoma of the floor of the mouth, as a complication secondary to a failed attempt of dental implant removal at the anterior mandible. The proximity of the implant to the lingual vascular canal might have served as a cause for vascular damage during explantation.
Conclusions: Implant removal complications are scarcely described in the literature. Nonetheless, damaging blood vessels during explantation should not be underestimated. Computed tomography (CT) may be of value not only in preoperative implant planning but also before implant removal in jeopardized anatomical zones such as the anterior mandible. Lingual vascular canals should be looked for on computed tomography scans.

Extramaxillary Zygomatic Implants: An Alternative Approach for the Reconstruction of the Atrophic Maxilla.

BACKGROUND: Limited bone quality in the posterior maxilla results in low success rates for dental implants. Various bone augmentation methods have been described, yet most require two-step surgical procedures with relatively high rates of resorption and failure. An alternative for these patients is zygomatic implants. Zygomatic implants utilize the basal craniofacial bone. MATERIALS AND METHODS: A retrospective study was conducted on 25 patients exhibiting ridges classified as V-VI according to the Cawood and Howell classification. Seventy-six extramaxillary zygomatic implants were placed. Immediate rehabilitation was performed with a mean follow-up of 18.6 months. RESULTS: Three implants failed, and two were replaced successfully. No significant bone loss was observed in the rest of the implants. Soft tissue around the implant heads healed properly. All implants were prosthetically rehabilitated successfully. CONCLUSIONS: Zygomatic implants allow for immediate loading of an atrophic maxilla. The emergence of the implant is prosthetically correct compared to the intrasinus approach, leading to better dental hygiene and decreased mechanical resistance. 96.1% of the implants survived, with good anchorage and proper soft tissue healing and rehabilitation. We suggest using extramaxillary zygomatic fixture as the first line of treatment in severe atrophic maxilla.

3D Planning and Printing of Patient Specific Implants for Reconstruction of Bony Defects.

We are in the midst of the 3D era in most aspects of life, and especially in medicine. The surgical discipline is one of the major players in the medical field using the constantly developing 3D planning and printing capabilities. Computer-assisted design (CAD) and computer assisted manufacturing (CAM) are used to describe the 3D planning and manufacturing of the product. The planning and manufacturing of 3D surgical guides and reconstruction implants is performed almost exclusively by engineers. As technology advances and software interfaces become more user-friendly, it raises a question regarding the possibility of transferring the planning and manufacturing to the clinician. The reasons for such a shift are clear: the surgeon has the idea of what he wants to design, and he also knows what is feasible and could be used in the operating room. It allows him to be prepared for any scenario/unexpected results during the operation and allows the surgeon to be creative and express his new ideas using the CAD software. The purpose of this method is to provide clinicians with the ability to create their own surgical guides and reconstruction implants. In this manuscript, a detailed protocol will provide a simple method for segmentation using segmentation software and implant planning using a 3D design software. Following the segmentation and stl file production using segmentation software, the clinician could create a simple patient specific reconstruction plate or a more complex plate with a cradle for bone graft positioning. Surgical guides can be created for accurate resection, hole preparation for proper reconstruction plate positioning or for bone graft harvesting and re-contouring. A case of lower jaw reconstruction following plate fracture and nonunion healing of a trauma sustained injury is detailed.

Direct on-the-spot detection of SARS-CoV-2 in patients.

IMPACT STATEMENT: Humanity is currently experiencing a global pandemic with devastating implications on human health and the economy. Most countries are gradually exiting their lockdown state. We are currently lacking rapid and simple viral detections, especially methods that can be performed in the household. Here, we applied RT-LAMP directly on human clinical swabs and self-collected saliva samples. We adjusted the method to allow simple and rapid viral detection, with no RNA purification steps. By testing our method on over 180 human samples, we determined its sensitivity, and by applying it to other viruses, we determined its specificity. We believe this method has a promising potential to be applied world-wide as a simple and cheap surveillance test for SARS-CoV-2.

Niche rather than origin dysregulates mucosal Langerhans cells development in aged mice.

Unlike epidermal Langerhans cells (LCs) that originate from embryonic precursors and are self-renewed locally, mucosal LCs arise and are replaced by circulating bone marrow (BM) precursors throughout life. While the unique lifecycle of epidermal LCs is associated with an age-dependent decrease in their numbers, whether and how aging has an impact on mucosal LCs remains unclear. Focusing on gingival LCs we found that mucosal LCs are reduced with age but exhibit altered morphology with that observed in aged epidermal LCs. The reduction of gingival but not epidermal LCs in aged mice was microbiota-dependent; nevertheless, the impact of the microbiota on gingival LCs was indirect. We next compared the ability of young and aged BM precursors to differentiate to mucosal LCs. Mixed BM chimeras, as well as differentiation cultures, demonstrated that aged BM has intact if not superior capacity to differentiate into LCs than young BM. This was in line with the higher percentages of mucosal LC precursors, pre-DCs, and monocytes, detected in aged BM. These findings suggest that while aging is associated with reduced LC numbers, the niche rather than the origin controls this process in mucosal barriers.

Impaired Differentiation of Langerhans Cells in the Murine Oral Epithelium Adjacent to Titanium Dental Implants.

Peri-implantitis is a destructive inflammatory process affecting tissues surrounding dental implants and it is considered a new global health concern. Human studies have suggested that the frequencies of Langerhans cells (LCs), the main antigen-presenting cells (APCs) of the oral epithelium, are dysregulated around the implants. Since LCs play a role in regulating oral mucosal homeostasis, we studied the impact of dental titanium implants on LC differentiation using a novel murine model. We demonstrate that whereas the percentage of LC precursors (CD11c+MHCII+) increased in the peri-implant epithelium, the frequencies of LCs (CD11c+MHCII+EpCAM+langerin+) were significantly reduced. Instead, a population of partially developed LCs expressing CD11c+MHCII+EpCAM+ but not langerin evolved in the peri-implant mucosa, which was also accompanied by a considerable leukocyte infiltrate. In line with the increased levels of LC precursors, expression of CCL2 and CCL20, chemokines mediating their translocation to the epithelium, was elevated in the peri-implant epithelium. However, expression of TGF-ß1, the major cytokine driving final differentiation of LCs, was reduced in the epithelium. Further analysis revealed that while the expression of the TGF-ß1 canonical receptor activing-like kinase (ALK)5 was upregulated, expression of its non-canonical receptor ALK3 was decreased. Since titanium ions releasing from implants were proposed to alter APC function, we next analyzed the impact of such ions on TGF-ß1-induced LC differentiation cultures. Concurring with the in vivo studies, the presence of titanium ions resulted in the generation of partially developed LCs that express CD11c+MHCII+EpCAM+ but failed to upregulate langerin expression. Collectively, these findings suggest that titanium dental implants have the capacity to impair the development of oral LCs and might subsequently dysregulate immunity in the peri-implant mucosa.

Porphyromonas gingivalis Promotes Unrestrained Type I Interferon Production by Dysregulating TAM Signaling via MYD88 Degradation.

Whereas type I interferons (IFNs-I) were proposed to be elevated in human periodontitis, their role in the disease remains elusive. Using a bacterial-induced model of murine periodontitis, we revealed a prolonged elevation in IFN-I expression. This was due to the downregulation of TAM signaling, a major negative regulator of IFN-I. Further examination revealed that the expression of certain TAM components was reduced as a result of prolonged degradation of MYD88 by the infection. As a result of such prolonged IFN-I production, innate immunological functions of the gingiva were disrupted, and CD4+ T cells were constitutively primed by dendritic cells, leading to elevated RANKL expression and, subsequently, alveolar bone loss (ABL). Blocking IFN-I signaling restored proper immunological function and prevented ABL. Importantly, a loss of negative regulation on IFN-I expression by TAM signaling was also evident in periodontitis patients. These findings thus suggest a role for IFN-I in the pathogenesis of periodontitis.