Is the "Habsburg jaw" related to inbreeding?

Background: The "Habsburg jaw" has long been associated with inbreeding due to the high prevalence of consanguineous marriages in the Habsburg dynasty. However, it is thought that mandibular prognathism (MP) is under the influence of a dominant major gene.Aim: To investigate the relationship between the "Habsburg jaw" and the pedigree-based inbreeding coefficient (F) as a relative measure of genome homozygosity.Subjects and methods: The degree of MP and maxillary deficiency (MD) of 15 members of the Habsburg dynasty was quantified through the clinical analysis of 18 dysmorphic features diagnosed from 66 portraits.Results: A statistically significant correlation (r = 0.711, p = 0.003) between MP and MD was observed among individuals. Only MP showed a statistically significant positive regression on F as evidenced from univariate analysis (b = 6.36 ± 3.34, p = 0.040) and multivariate analysis (PCA) performed from single dysmorphic features (b = 14.10 ± 6.62, p = 0.027, for the first PC).Conclusion: Both MP and MD are generally involved in the "Habsburg jaw." The results showed a greater sensitivity to inbreeding for the lower third of the face and suggest a positive association between the "Habsburg jaw" and homozygosity and therefore a basically recessive inheritance pattern.

Horizontal Bone Augmentation Using Autogenous Block Grafts and Particulate Xenograft in the Severe Atrophic Maxillary Anterior Ridges: A Cone-Beam Computerized Tomography Case Series.

The aim of the present study was to use cone-beam computerized tomography (CBCT) to assess horizontal bone augmentation using block grafts, harvested from either the iliac crest (IC) or mandibular ramus (MR) combined with particulate xenograft and a collagen membrane for in the severe maxillary anterior ridge defects (cases Class III-IV according to Cadwood and Howell's classification). Fourteen healthy partially edentulous patients requiring extensive horizontal bone reconstruction in the anterior maxilla were selected for the study. Nineteen onlay block grafts (from IC or MR) were placed. The amount of horizontal bone gain was recorded by CBCT at 3 levels (5, 7, and 11 mm from the residual ridge) and at the time of bone grafting as well as the time of implant placement (≈5 months). Both block donor sites provided enough ridge width for proper implant placement. Nonetheless, IC had significantly greater ridge width gain than MR (Student t test) (4.93 mm vs 3.23 mm). This was further confirmed by nonparametric Mann-Whitney test (P = .007). Moreover, mean pristine ridge and grafted ridge values showed a direct association (Spearman coefficient of correlation = .336). A combination of block graft, obtained from the IC or MR, combined with particulate xenograft then covered with an absorbable collagen membrane is a predictable technique for augmenting anterior maxillary horizontal ridge deficiency.

Comparison between microcomputed tomography and cone-beam computed tomography radiologic bone to assess atrophic posterior maxilla density and microarchitecture.

PURPOSE: The aim of this study was to analyze the relationship between bone density obtained by cone-beam computed tomography (CBCT) and morphometric parameters of bone analyzed by microcomputed tomography (µ-CT). MATERIAL AND METHODS: An overall of 32 subjects ≤8 mm of bone height were included in the study. One site per patient was randomly selected to obtain bone core. Totally, 27 biopsies were available for µ-CT analysis. In addition, CBCT was taken after positioning a previously fabricated acrylic resin template with a 2-mm-diameter metal rod at the randomly selected implant site to study radiographic bone density (RBD). The relationship between µ-CT and CBCT quantitative variable and RBD was analyzed using Spearman correlation. RESULTS: Positive correlations between BV/TV (r = 0.769, P < 0.001), BS/TV (r = 0.563, P = 0.002), Tb.Th (r = 0.491, P = 0.009), Tb.N (r = 0.518, P = 0.005) and vBMD (r = 0.699, P < 0.001) with RBD were identified. On the contrary, BS/BV (r = -0.509, P = 0.006), Tb.Sp (r = -0.539, P = 0.003) and Tb.Pf (r = -0.636, P < 0.001) were negatively correlated with RBD. Moreover, SMI (r = -0.380, P = 0.050) and DA (-0.245, P = 0.217) were negatively correlated but not statistically significant. CONCLUSION: This study demonstrated the correlation between radiographic bone density (RBD) and bone density assessed by µ-CT. Therefore, our data supported the use of CBCT as pre-operative tool for implant treatment planning because it is shown to be reliable to assess atrophic posterior maxilla density and microarchitecture.

The reliability of cone-beam computed tomography to assess bone density at dental implant recipient sites: a histomorphometric analysis by micro-CT.

OBJECTIVES: The aim of this study was to objectively assess the reliability of the cone-beam computed tomography (CBCT) as a tool to pre-operatively determine radiographic bone density (RBD) by the density values provided by the system, analyzing its relationship with histomorphometric bone density expressed as bone volumetric fraction (BV/TV) assessed by micro-CT of bone biopsies at the site of insertion of dental implants in the maxillary bones. MATERIAL AND METHODS: Thirty-nine bone biopsies of the maxillary bones at the sites of 39 dental implants from 31 edentulous healthy patients were analyzed. The NobelGuide™ software was used for implant planning, which also allowed fabrication of individual stereolithographic surgical guides. The analysis of CBCT images allowed pre-operative determination of mean density values of implant recipient sites along the major axis of the planned implants (axial RBD). Stereolithographic surgical guides were used to guide implant insertion and also to extract cylindrical bone biopsies from the core of the exact implant site. Further analysis of several osseous micro-structural variables including BV/TV was performed by micro-CT of the extracted bone biopsies. RESULTS: Mean axial RBD was 478 ± 212 (range: 144-953). A statistically significant difference (P = 0.02) was observed among density values of the cortical bone of the upper maxilla and mandible. A high positive Pearson's correlation coefficient (r = 0.858, P < 0.001) was observed between RBD and BV/TV, with the regression equations: (1) Axial RBD = -19.974 + 10.238·BV/TV; (2) BV/TV = 14.258 + 0.72·Axial RBD. RBD was also positively correlated with the trabecular thickness (Tb.Th) and trabecular number (Tb.N), but negatively correlated with trabecular separation (Tb.Sp), structural model index, and inverse connectivity (Tb.Pf). Density values upper than 450 were associated with BV/TV upper than 50%, mean Tb.Th upper than 0.2 mm, mean Tb.Sp lower than 0.3 mm, and mean Tb.N upper than 2. CONCLUSION: RBD assessed by CBCT has a strong positive correlation with BV/TV assessed by micro-CT at the site of dental implants in the maxillary bones. Pre-operative estimation of density values by CBCT is a reliable tool to objectively determine bone density.

Is micro-computed tomography reliable to determine the microstructure of the maxillary alveolar bone?

OBJECTIVES: To analyze the reliability of micro-computed tomography (micro-CT) to assess bone density and the microstructure of the maxillary bones at the alveolar process in human clinics by direct comparison with conventional stereologic-based histomorphometry. MATERIALS AND METHODS: Analysis of osseous microstructural variables including bone volumetric density (BV/TV) of 39 biopsies from the maxillary alveolar bone was performed by micro-CT. Conventional stereologic-based histomorphometry of 10 bone biopsies was performed by optic microscopy (OM) and low-vacuum surface electronic microscopy (SEM). Percentages of bone between micro-CT and conventional stereologic-based histomorphometry were compared. RESULTS: Significant positive correlations were observed between BV/TV and the percentage of bone (%Bone) analyzed by SEM (r = 0.933, P < 0.001), by toluidine blue staining OM (r = 0.950, P < 0.001) and by dark field OM (r = 0.667, P = 0.05). The high positive correlation coefficient between BV/TV and trabecular thickness illustrates that a value of BV/TV upper than 50% squares with a bone presenting most of their trabecules thicker than 0.2 mm. The high negative correlation between BV/TV and trabecular separation shows that values of BV/TV upper than 50% squares with a bone presenting most of their trabecules separated less than 0.3 mm each other. CONCLUSION: BV/TV assessed by micro-CT correlates with the percentage of bone assessed by conventional stereologic-based histomorphometry. Micro-CT is a reliable technique to determine the bone density and the microstructure of the maxillary alveolar bone at the site of dental implant insertion.

Characteristics of newly formed bone in sockets augmented with cancellous porous bovine bone and a resorbable membrane: microcomputed tomography, histologic, and resonance frequence analysis.

AIM: Microcomputed tomography (micro-CT) has become a highly accurate and nonintrusive method for analysis of bone. This study aims to determine the microstructural characteristics of the bone formed in grafted extraction sockets. METHODS: This prospective study comprised 10 patients. Cancellous porous bovine bone (CPBB) was used for socket grafting. Ten bone samples were harvested from implant site 9 months after grafting, before implant placement, and histologic and microstructural characteristics were analyzed. Cone-beam computed tomography scans were performed, and implant stability was also determined. RESULTS: Four men and 6 women, with a mean age of 44 years, were included in the study. Micro-CT revealed a compact structure with high bone volume fraction, trabecular thickness and number, but a low trabecular separation and pattern factor, which made it an optimal structure that is expected to resist occlusal loads. Histologic examination revealed an abundant amount of CPBB particles (27.5%) and new bone formation (23.3%) 40.6 months after bone grafting surgery. Moreover, mean implant stability quotient was 75.7 units. CONCLUSION: This investigation demonstrated marked de novo bone formation after a healing period of 9 months. This trabecular bone had a compact structure with abundant thick trabeculae.

Comparison of implant primary stability between maxillary edentulous ridges receiving intramembranous origin block grafts.

PURPOSE: The purposes of the present study were: to compare the resonance frequency analysis (RFA) values of implant placed in either ramus or calvaria block grafts; and to determine if implant diameter influences RFA implant stability quotient (ISQ) value. MATERIAL AND METHODS: This was a retrospective study that included 16 consecutives healthy patients treated with autogenous onlay block grafts for horizontal bone reconstruction in maxilla. Ten ramus and ten calvaria block graft treated patients were selected and compared. RESULTS: Totally, 59 implants were placed, 35 (59.3%) were placed on the calvaria bone grafts and the remaining 24 (40.7%) were on the ramus bone graft. Of all the implants studied, 13 (22%), 35 (59.3%), and 11 (18.6%) were 10 mm, 11.5 mm and 13 mm in length respectively. Regarding the diameter, 4 (7%) were 3.3 mm, 3 (5%) were 3.5 mm, 20 (34%) were 3.7 mm and 32 (54%) were 4 mm. Mean ISQ value obtained by RFA was 73.06 ± 6.08, being 72.19 ± 6 and 74.47 ± 6.06 for the calvaria and ramus treated group respectively. No significant differences were noted between the two groups (p= 0.154). Implants were pooled and divided by their diameter. Mean ISQ value obtained for 3.3 mm was 80 ± 5.09, while for 4.0 mm was 72.5 ± 7.19. Again, no significant differences were found among the groups (p= 0.138). CONCLUSION: For RFA ISQ value, the bone graft origins (calvaria or ramus) or implant diameters did not influence the outcome.

Osseointegrated implant rehabilitation of irradiated oral cancer patients.

PURPOSE: The aim of this study is to analyze implant survival in patients who received radiotherapy treatment for oral malignancies and in patients who had suffered mandibular osteoradionecrosis. MATERIALS AND METHODS: We reviewed retrospectively 225 implants placed in 30 patients who had received radiotherapy as part of the oncologic treatment. Radiation doses ranged between 50 and 70 Gy. 39 implants were placed after a combined treatment of radiotherapy and chemotherapy. Data referred to tumour type and reconstruction, presence of osteoradionecrosis, region of implant installation and type of prostheses were recorded. Survival rates were calculated with cumulative Kaplan-Meier survival curves and compared between different groups with a log-rank test. RESULTS: 152 osseointegrated implants were placed in patients who presented previous reconstruction procedure. Five patients developed osteorradionecrosis as a complication of the radiotherapy treatment. Once osteoradionecrosis had healed in these patients, 41 implants were installed. The overall 5 year survival rate in irradiated patients was 92.6%. Irradiated patients had a marginally significantly higher implant loss than non-irradiated patients. (p = 0.063). The 5 year survival rate in the osteoradionecrosis group was of 48.3% and in the non-osteoradionecrosis group 92.3%, with a statistically significant difference between both groups. (p = 0.002). CONCLUSION: Osseointegrated implants enhance oral rehabilitation in most irradiated patients, even being an acceptable option for patients who had suffered osteoradionecrosis. Totally implant supported prostheses are recommended after irradiation providing functional, stable and aesthetically satisfactory rehabilitation.

Arthroscopic Disc Repositioning Techniques of the Temporomandibular Joint Part 2: Resorbable Pins.

Arthroscopic rigid fixation (ARF) of the temporomandibular joint (TMJ) with resorbable pins and other advanced arthroscopic disc repositioning (ADR) techniques by sutures has provided a renewed interest in the role played by the disc in the treatment of the most severe cases of TMJ ID with anterior disc displacement with severe limitation of mouth opening. These techniques may be the last step prior to open TMJ surgery, if other less complex operative arthroscopic techniques (OAT) have previously failed, or for those cases in which no predictable results are expected with simpler OAT due to the presence of a severe displaced disc or closed lock. In this article, ARF with resorbable pins is being approached, with a special focus on describing the technique while reporting its advantages and disadvantages. Also, potential complications and postoperative management and recovery, together with some advice in terms of pearls and pitfalls will be exposed.

Hyperplasia of the mandibular condyle: clinical, histopathologic, and treatment considerations in a series of 36 patients.

PURPOSE: Mandibular condylar hyperplasia (CH) is a rare entity that causes overdevelopment of the mandible, creating functional and esthetic problems. The aim of this article was to describe demographic and clinical characteristics of CH, analyze histopathologic features and their association with scintigraphic and clinical findings, and evaluate esthetic and functional results after treatment by high condylectomy during the active phase. MATERIALS AND METHODS: This retrospective study included 36 patients whose condyles were removed because of excessive unilateral growth resulting in facial asymmetry and occlusal disturbance. Of the 36 patients, 13 had had symptoms related to the temporomandibular joint, such as pain or clicking. In all the cases, high condylectomy was performed, and surgical specimens were sent for histologic examination and divided into 4 histologic types as described by Slootweg and Müller. Statistical analysis was performed by use of R software (version 2.10.1; R Foundation for Statistical Computing, Vienna, Austria) and SPSS software for Windows (version 15.0; SPSS, Chicago, IL) to evaluate our results. A χ(2) test was carried out to assess the possible association between gender and involved side. The association of histologic appearance with clinical symptoms was estimated by use of the Fisher exact test. An analysis of variance test was performed to evaluate a possible association between patient age and histologic type according to the Slootweg and Müller classification and between histologic type and uptake on bone single photon emission computed tomography (SPECT). RESULTS: We could not find a relationship between histologic type and uptake of the affected condyle on bone SPECT or between age and histologic type. However, our statistical analysis revealed an association between histologic appearance and the presence of joint symptoms (P = .0049). Clinically, occlusion and facial symmetry improved in all patients postoperatively, and no recurrence was noted in any patient. Six patients required secondary surgery. CONCLUSION: We could not find any significant association between age and histologic type or between bone SPECT and histologic type. However, a significant association between histologic type and temporomandibular joint symptoms was observed. High condylectomy combined with orthodontics achieved optimal esthetic and functional results and constituted the unique and definitive treatment in 30 of 36 patients.

Arthroscopic lysis and lavage versus operative arthroscopy in the outcome of temporomandibular joint internal derangement: a comparative study based on Wilkes stages.

PURPOSE: To assess whether arthroscopic lysis and lavage (ALL) or operative arthroscopy (OA) is more effective for the treatment of temporomandibular joint (TMJ) internal derangement at any stage of involvement. PATIENTS AND METHODS: In 458 patients (611 joints) with internal derangement of the TMJ classified as Wilkes stages II through V, arthroscopy was performed. Pain (visual analog scale score, 0-100) and maximal interincisal opening were assessed at 1, 3, 6, 9, 12, and 24 months after surgery. RESULTS: ALL was performed in 308 of 611 arthroscopies (50.4%), and OA was performed in 303 arthroscopies (49.59%). A significant decrease in pain (P < .001) was observed for all patients at any time during the follow-up period from the first month postoperatively to the end of the 2-year follow-up period. A highly significant increase in mouth opening greater than 13 mm was observed in the group of patients classified as Wilkes stage IV from the first month postoperatively. When we compared ALL versus OA among Wilkes stages, no significant differences in terms of pain were observed during the entire follow-up period. CONCLUSIONS: Both ALL and OA are equally effective at decreasing pain in patients with TMJ internal derangement of any Wilkes stage. Patients classified as Wilkes stage IV presenting with chronic closed lock of the TMJ had the highest decrease in pain and the highest increase in mouth opening among the stages, thus confirming these patients as the best candidates for arthroscopy.

Vertical distraction osteogenesis of a free vascularized fibula flap in a reconstructed hemimandible for mandibular reconstruction and optimization of the implant prosthetic rehabilitation. Report of a case.

Free vascularized fibular flap is considered the treatment of choice in mandibular reconstruction for extensive bone defects (over 6 centimeters) resulting from trauma, infections or tumor resections. But, when the reconstruction involves a dentate mandible, the fibula has the limit as it does not offer sufficient bone height to restore the alveolar arch up to the occlusal plane. Therefore, the deficiency in bone height makes implant placement impractical. We report a case of vertical distraction osteogenesis of a free vascularized fibula flap used to reconstruct a hemimandible after resection of an odontogenic myxoma, for optimization of the implant prosthetic rehabilitation. The distraction device was applied intraorally. After 10 days of latency period, distraction protocol was performed at a distraction rate of 0.5 mm per day. A consolidation period of 3 months followed. Afterwards the distraction device was removed and 3 osseointegrated dental implants were placed in the distracted area. As a result, the vertical discrepancy between the fibula and the native hemimandible was corrected. The amount of vertical height achieved after distraction was 17 milimeters. The increase of vertical bone height was stable and enabled placement of dental implants without any complications. In conclusion, we consider that vertical distraction osteogenesis of free vascularized flaps is a reliable technique that optimizes implant positioning for ideal prosthetic rehabilitation, after mandibular reconstruction following tumor surgery.

A randomized controlled preclinical trial on 3 interposal temporomandibular joint disc implants: TEMPOJIMS-Phase 2.

The effort to develop an effective and safe temporomandibular joint (TMJ) disc substitute has been one of the mainstreams of tissue engineering. Biodegradable customized scaffolds could approach safety and effectiveness to regenerate a new autologous disc, rather than using non-biodegradable materials. However, it is still technically challenging to mimic the biomechanical properties of the native disc with biodegradable polymers. In this study, new 3D tailored TMJ disc implants were developed: (1) Poly(glycerol sebacate) (PGS) scaffold reinforced with electrospun Poly(εcaprolactone) (PCL) fibers on the outer surface (PGS+PCL); (2) PCL and polyethylene glycol diacrylate (PEGDA) (PCL+PEGDA); and (3) PCL. The TMJ implants were tested in a randomized preclinical trial, conducted in 24 black Merino sheep TMJ, perfoming bilateral interventions. Histologic, imaging, and kinematics analysis was performed. No statistical changes were observed between the PGS+PCL disc and the control group. The PCL+PEGDA and PCL groups were associated with statistical changes in histology (p = 0.004 for articular cartilage mid-layer; p = 0.019 for structure changes and p = 0.017 for cell shape changes), imaging (p = 0.027 for global appreciation) and dangerous material fragmentation was observed. No biomaterial particles were observed in the multi-organ analysis in the different groups. The sheep confirmed to be a relevant animal model for TMJ disc surgery and regenerative approaches. The PCL and PCL+PEGDA discs presented a higher risk to increase degenerative changes, due to material fragmentation. None of the tested discs regenerate a new autologous disc, however, PGS+PCL was safe, demonstrated rapid resorption, and was capable to prevent condyle degenerative changes.

A 12-year retrospective analytic study of the implant survival rate in 177 consecutive maxillary sinus augmentation procedures.

PURPOSE: This retrospective study sought to demonstrate the outcome of maxillary sinus elevation surgery in a series of 177 procedures performed over 12 years and to determine the existence of variables that could independently predict implant survival. MATERIALS AND METHODS: A retrospective descriptive and analytic study of a series of maxillary sinus elevation procedures performed between 1996 and 2007 was undertaken. The sample was composed of patients with severe atrophy of the posterior maxilla who had been rehabilitated with osseointegrated implants placed in grafted maxillary sinuses. Several features of the patients (smoking habit, presence of comorbidities, and previous oral carcinoma) and of the surgical procedure (grafting material, associated procedures, associated materials, simultaneous/delayed implant placement, and complications) related to implant survival or failure were monitored during the follow-up period. Implant survival and the existence of variables that could predict implant survival independently were analyzed statistically. RESULTS: One hundred seventy-seven sinus augmentation procedures were performed in 119 consecutive patients (mean age 50.02 years; SD 11.5). Of the 272 implants placed in sinus-augmented regions, 19 were lost. The mean follow-up period was 60.7 months (SD 36.5). The overall cumulative implant survival rate was 93% after 5 years. The multivariate analysis showed that the presence of complications related to the sinus augmentation procedure (membrane perforation and sinusitis) and peri-implantitis were factors in predicting implant failure. CONCLUSIONS: On the basis of this retrospective analysis, it might be concluded that sinus augmentation is a very versatile procedure. Its efficacy and predictability in terms of implant survival rate is extremely high and independent of the graft material, surgical technique, associated comorbidities, smoking habits, and timing of implant placement. Complications such as membrane perforation, sinusitis, and peri-implantitis appeared to influence implant failure.

Influence of the upper joint surface and synovial lining in the outcome of chronic closed lock of the temporomandibular joint treated with arthroscopy.

PURPOSE: Temporomandibular joint (TMJ) arthroscopy has been reported to be an effective and reliable technique for the treatment of chronic closed lock (CCL) of the TMJ. The purpose of the present study was to evaluate whether the status of the joint surface and the synovial lining directly visualized with arthroscopy could determine postoperative results in patients with CCL of the TMJ. MATERIALS AND METHODS: In all, 257 of 500 patients (344 joints) fulfilled the inclusion criteria for CCL of the TMJ. Of these patients, 172 with unilateral TMJ involvement were finally selected for the study. Synovitis and chondromalacia were chosen as the main features for evaluation of the joint surface and synovial lining. Two groups of patients were established: 1) patients with scarce affectation (synovitis grades I-II and chondromalacia grades I-II); and 2) patients with severe affectation (synovitis grades III-IV and/or chondromalacia grades III-IV). Pain and maximal interincisal opening were chosen as dependent variables. All patients were assessed at 1, 3, 6, 12, and 24 months postoperatively. The paired-samples Student's t test was used to compare mean values for pain (using a visual analog scale) and maximal interincisal opening (MIO) both pre- and postoperatively. The Student's t test for unpaired data was applied for the statistical analysis. A P value less than .05 was considered statistically significant. RESULTS: Synovitis grades I-II were arthroscopically observed in 87 (50.58%) patients, whereas synovitis grades III-IV were present in 72 (41.86%) patients. Chondromalacia grades I-II were arthroscopically observed in 66 (38.37%) patients, whereas chondromalacia grades III-IV were present in 54 (31.39%) patients. A statistically significant decrease in pain (P < .001) with a parallel increase in mouth opening (P < .001) after arthroscopy was observed for patients with synovitis I-II, synovitis III-IV, chondromalacia I-II, and chondromalacia III-IV during the whole follow-up period. A significant difference (P = .01) in relation to VAS score was observed between patients with synovitis I-II and patients with synovitis III-IV at month 6 postoperatively. However, this difference did not persist during the rest of the follow-up period, as was the case in relation to mouth opening. No significant differences were observed in relation to decrease of pain and increase of MIO between patients with chondromalacia I-II and patients with chondromalacia III-IV at any time during the follow-up period. Although mean values for pain were lower in patients with synovitis I-II plus chondromalacia I-II in comparison to patients with synovitis III-IV plus chondromalacia III-IV for the whole follow-up period, no statistical significant differences were observed. In relation to the increase in mouth opening, slightly higher values were observed for patients with synovitis I-II plus chondromalacia I-II, although no statistical differences were observed with regard to patients presenting with synovitis III-IV plus chondromalacia III-IV. CONCLUSION: A significant decrease in pain with a parallel increase in MIO was achieved from month 1 postoperatively in patients with any grade of synovitis and/or chondromalacia. No statistical difference in pain or function was observed between patients with scarce involvement of the joint surface and the synovial lining and patients with severe involvement after arthroscopy.

Long-Term Dislocation of the Mandible: Is there an Algorithm to Success? Intraoperative Decision and Review of Literature.

PURPOSE: Long-term TMJ dislocation is a rare condition. It occurs when an acute luxation remains untreated in time. METHODS: A 52-year-old man presented with a long-term TMJ luxation in the context of Steinert's disease. A discectomy together with condylectomy and eminectomy was performed, obtaining an adequate reduction of the luxated condyle and disc. RESULTS: Twelve months after the operation, the condition has not recurred at all. A stable and centred occlusion was checked; his MIO was over 30 mm. CONCLUSION: The combination of these three techniques could be a good option in cases of Steinert's myotonia, where the condyle luxation becomes chronic and irreducible due to the altered neuromuscular condition. There is still no consensus regarding the treatment for long-term TMJ dislocations. New and more solid studies may be needed in order to find adequate treatment protocols for this condition.

Reconstruction of oromandibular defects by vascularized free flaps: the radial forearm free flap and fibular free flap as major donor sites.

PURPOSE: Since the advent of the modern microvascular techniques, the radial forearm free flap (RFFF) and the vascularized fibular free flap (VFFF) have become reliable methods for reconstructing oromandibular defects. The purpose of this study is to evaluate our experience with the use of both free flaps in the reconstruction of oral cavity defects after tumoral ablation. PATIENTS AND METHODS: Over a 9-year period, 103 consecutive patients were treated in our department for the reconstruction of oral defects after tumor ablation by means of microvascularized free flaps. A total of 55 patients underwent reconstruction using RFFFs; 42 patients underwent reconstruction using VFFFs with or without skin paddles. Patients were treated for benign (n = 15) and malignant (n = 82) entities. All but 7 patients received donor site covering with abdominal full-thickness skin grafts. RESULTS: Of the 55 patients who received RFFFs, 5 (9.09%) developed necrosis at the end of the postsurgical period, and 7 patients developed complications of the donor site. Of the 42 patients who received VFFFs, an overall flap survival rate of 92.85% was achieved, and complications at the donor site occurred in 5 patients. For both free flaps, anesthesia time lasted from 6 to 15 hours (mean, 9.57 hours), whereas the mean flap ischemic time was 82.86 minutes. CONCLUSIONS: Our results reveal that the RFFF is a reliable method for reconstructing a wide range of oral cavity defects with an acceptably low morbidity rate. It provides adequate bulk and pliability, enabling the reconstruction of a wide variety of locations within the oral cavity. The VFFF allows good reconstruction of composite mandibular defects and provides adequate support for dental implants.

Costochondral graft with green-stick fracture used in reconstruction of the mandibular condyle: experience in 13 clinical cases.

Since its publication in 1920 by Gillies, costochondral grafts have been used by surgeons to replace and injured mandibular condyle and to reconstruct the temporomandibular joint. This procedure is currently applied in cases of congenital dysplasia, developmental defects, temporomandibular ankylosis, neoplastic disease, osteoarthritis and post-traumatic dysfunction. Over the years, various procedures for the reconstruction with this type of graft have been described. In 1989, Mosby and Hiatt described a technique for setting the graft securely, reducing the space between the graft and the mandibular area. In 1998, Monje and Martín-Granizo developed a variation of this method, enabling a precise adaptation of the costochondral graft to the remaining mandibular ramus. The aim of this study is to evaluate the functional and anatomic results of the costochondral graft treatment by green-stick fracture for reconstruction of the TMJ in the 10 years following the description of this technique. We carry out a retrospective study of thirteen cases of temporomandibular pathology (tumors, ankylosis and hypoplasia) treated during a period of ten years from 1998 to 2008. In all these cases, the technique described by Monje and Martín-Granizo was used: removal of the sixth rib, fixation to a titanium mini-plate using screws, making an internal corticotomy in order to obtain a green-stick fracture of the outer cortex, providing adequate adaptation of the graft to the mandibular ramus. The graft was then set in place, attaching it with titanium screws. This technique was successful in achieving optimal ossification, a good interincisal opening and satisfactory cosmetic results. In conclusion, according to our experience, the green-stick fracture for the adaptation of costochondral grafts to the remaining mandibular ramus has presented outstanding results in the surgical treatment of temporomandibular pathology.

Metastasis of renal clear-cell carcinoma to the oral mucosa, an atypical location.

The majority of cases of metastatic tumors involve the mandible and some the maxilla but they are considerably less common in intraoral soft tissues. In addition, the primary tumor is known in the majority of cases; although in one-third of such cases, metastasis is the first clinical manifestation. The most common primary tumors metastasizing to the mouth are lung carcinoma in men and breast carcinoma in women. An oral metastasis implies a serious prognosis, as in the majority of patients there is multiple organ involvement at the time of diagnosis. We present the case of a 52-year old patient with renal pathology who came to the emergency room due to a rapidly increasing gingival tumor. With the provisional clinical diagnosis of a pyogenic granuloma,the tumor was excised. Subsequent anatomopathological analysis revealed a tumor metastasis compatible with clear-cell carcinoma, and its renal origin was confirmed by means of immunohistochemical techniques.

Vascularized fibular flap for reconstruction of the condyle after mandibular ablation.

PURPOSE: The purpose of this study was to evaluate the outcome of the vascularized fibular free flap for the reconstruction of mandibular resections involving the condylar segment. PATIENTS AND METHODS: Six patients underwent mandibular resection including the condyle. Two patients were diagnosed with squamous cell carcinoma, whereas the other 4 presented fibrous dysplasia, mandibular osteoradionecrosis, mandibular ameloblastoma, and giant cell granuloma of the mandible. All of them underwent condylar reconstruction by means of transplant of the free fibular flap. In all the cases, the fibula was placed directly into the glenoid fossa. The temporomandibular disc was preserved over the pole of the fibula. Panoramic radiographs were performed postoperatively to evaluate condylar position and grade of bone resorption. RESULTS: Five patients developed adequate temporofibular function with absence of hypomobility and optimum interincisal opening, whereas 1 patient developed a temporofibular ankylosis with severe limitation of mandibular mobility and mouth opening. CONCLUSIONS: The use of the fibula flap directly fitted into the glenoid fossa constitutes a reliable method in condylar reconstruction. However, the possibility of severe complications such as ankylosis has to be considered.