Immediate mobilization following fixation of mandible fractures: a prospective, randomized study.

OBJECTIVES: To compare outcomes of open reduction and internal fixation of displaced mandible fractures followed by either immediate mobilization or 2 weeks of mandibular-maxillary fixation. STUDY DESIGN: A prospective, randomized, single-blinded study was performed. METHODS: The study was performed between January 1, 1997, and March 30, 2000. Inclusion criteria were displaced fractures between the mandibular angles, age greater than 16 years, and no involvement of the alveolus, ramus, condyles, or maxilla. All fractures were repaired by means of open reduction and internal fixation using 2.0-mm titanium plates secured either in transoral fashion or percutaneously. Data were collected at 6-week and 3- and 6-month postoperative examinations. Variables were assessed by a surgeon blinded to the history of immobilization and included pain, malunion or nonunion, occlusion, trismus, wound status, infection rates, dental hygiene, and weight loss. Twenty-nine consecutive patients were enrolled, 16 patients to immediate function and 13 patients to 2 weeks of mandibular-maxillary fixation. RESULTS: No statistically significant differences were found between groups for any of the variables. Immediate release and temporary immobilization showed mean weight loss of 10 and 8 pounds and trismus of 4.2 and 4.6 cm, respectively. One wound separation and one infection were seen in the immobilization population, and no wound separation or infection was seen in the immediate-release group. Dental hygiene was similar between the groups. No malunion or nonunion was noted in either group. CONCLUSIONS: In this prospective and randomized study, no significant differences were noted between the groups receiving either immediate release or 2 weeks of mandibular-maxillary fixation. The findings support the treatment of selective mandible fractures with 2.0-mm miniplates and immediate mobilization.

Hyperbaric oxygen for the management of radionecrosis of bone and cartilage.

OBJECTIVES: To review the use of hyperbaric oxygen in the management of radionecrosis of the head and neck. STUDY DESIGN: A retrospective analysis of patients utilizing chart review and telephone interviews. All patients diagnosed with osteoradionecrosis and chondroradionecrosis of the head and neck and treated with hyperbaric oxygen at the University of Virginia are included. METHODS: Demographics, pretreatment data, and precipitating events were recorded. Outcomes were evaluated using a grading scale of symptomatology and physical examination as determined by the patient and physician. RESULTS: Sixteen patients with osteoradionecrosis and five with chondroradionecrosis were reviewed. All patients showed clinical improvement with decreased pain following HBO therapy. None of the patients with chondroradionecrosis required laryngectomies, and two of the four who were tracheotomy dependent were successfully decannulated. The patient and physician grading scores demonstrated moderate to significant improvement in both groups following therapy. CONCLUSION: The successful use of hyperbaric oxygen for the management of radionecrosis of the head and neck is supported. The unusual prevalence of chondroradionecrosis may be an early reflection of changes in treatment protocols for patients with head and neck cancer.

Applications of hyperbaric oxygen in otolaryngology head and neck surgery: facial cutaneous flaps.

Hyperbaric oxygen therapy is of significant benefit in the setting of an ischemic flap of the head and neck. Mechanistically, hyperbaric oxygen decreases local tissue edema and improves oxygen delivery to compromised tissues. Both capillary and fibroblast in-growth occur at a greater rate with hyperbaric oxygen therapy, and there is an increase in the tensile strength of the wound. Additional indications in the head and neck include traumatic composite amputations, necrotizing soft-tissue infections, and osteoradionecrosis of the facial skeleton.

Adolescent gingival squamous cell carcinoma: Report of a case and review of the literature.

In this article we describe a case of adolescent squamous cell carcinoma of the gingiva. The tumor presented as an ulcerative lesion of the gingiva that was originally thought to be pseudoepitheliomatous hyperplasia. The pathologic differentiation between squamous cell carcinoma and pseudoepitheliomatous hyperplasia is discussed and a review of the literature with respect to pediatric and adolescent oral squamous cell carcinoma is presented. The reported case illustrates the difficulties that may be encountered in attempting to histopathologically distinguish between pseudoepitheliomatous hyperplasia and well-differentiated squamous cell carcinoma of the oral cavity.

Reduction in morbidity after iliac crest bone harvesting: the concept of preemptive analgesia.

The technique of autologous iliac crest bone grafting is an important aspect in the treatment of patients with cleft lip, cleft palate, and other craniofacial disorders. In patients with cleft lip and palate, the alveolar bone graft creates a continuous maxillary arch, closes the oronasal fistula, provides bony support for facial soft tissue and teeth, and facilitates orthodontic movement of teeth. The anatomic and physiologic benefits of this and similar autologous bone graft procedures are apparent. However, pain at the donor site represents a significant source of postoperative morbidity. This study was conducted to evaluate postoperative pain and the ability to perform activities of daily living after bupivacaine infiltration to iliac crest donor sites. Thirty-four alveolar bone graft patients (18 females, 16 males) treated at two teaching hospitals were included in the study. Eleven of the patients received intraoperative bupivacaine at the iliac donor site and 23 did not. A questionnaire was returned by all participants, and telephone follow-up was obtained. Responses to postoperative pain, time period to ambulation, and ability to perform activities of daily living were evaluated. Patients who received postoperative bupivacaine experienced delayed onset of postoperative pain, earlier ambulation, and were able to return to normal daily activity in a shorter period of time than those patients who received no local anesthesia. The concept of preemptive analgesia and its application to craniofacial surgery is discussed.

A new compound curved tapercut needle for oral surgery.

A new compound curved tapercut needle has been designed and developed for oral mucous membrane closure from a unique stainless steel alloy, American Society for Testing Materials (ASTM) 45500. This tapercut needle has a short, relatively straight point, followed by a curved distal section. Despite its geometry, it exhibited similar sharpness as well as resistance to bending and breakage, as did the standard tapercut needle with a single radius of curvature manufactured from the same alloy. The design of this new needle enabled the surgeon to pass it through the oral mucous membrane with a greater accuracy to a controlled depth and length of bite than the standard tapercut needle with a single radius of curvature. In addition, the new needle design aids in the suturing of mucous membranes in confined spaces.

Biomechanical performance of tapercut needles for oral surgery.

A new tapercut needle has been designed and developed for closure of the oral mucous membrane in oral surgery. It is a sharp needle with short cutting edges that easily penetrates through a small needle puncture hole. It is manufactured from a unique stainless steel alloy that resists bending and fracture. Biomechanical performance tests and clinical experience confirm its superiority over the standard reverse cutting edge needle for use in oral surgery.

Traumatic chronic TMJ dislocation: report of an unusual case and discussion of management.

Dislocation of the temporomandibular joint (TMJ) is most often spontaneous, but it can be associated with direct or indirect head and neck trauma. The disorder may be treated in general by simple closed techniques, if managed acutely. If the dislocation becomes chronic, however, open reduction is usually required. The article discusses various methods for an open surgical approach described in the literature. A case of a prolonged TMJ dislocation is presented, involving a severe bilateral mandibular dislocation with the condyles displaced into the infratemporal fossa and the lateral poles of the condyles articulating on the inner aspect of the zygomatic arch. An open approach, involving masseter, temporalis, and the medial pterygoid muscles, was utilized, followed by the use of scissors mouth props, Erich arch bars, and postoperative elastic traction.

Trigeminal neuralgia: a diagnostic challenge.

A 38-year-old white woman came to the emergency department complaining of severe, unilateral jaw pain. She had consulted her primary care physician and dentist without achieving the correct diagnosis or significant relief of her symptoms. The emergency physician made the diagnosis of trigeminal neuralgia by obtaining a history of severe paroxysmal ipsilateral facial pain activated by numerous facial stimuli. A light stimulation of the trigger point precipitated the pain. Her pain relief from carbamazepine lent further credence to the diagnosis of trigeminal neuralgia and appropriate referral to a neurosurgeon. Pain relief was ultimately achieved for the last 8 months by a neurectomy of the right infraorbital nerve.

Trends in temporomandibular joint surgery.

We examined a large population of patients undergoing temporomandibular joint (TMJ) surgery and provide a documentation of the average patient population, frequency of procedures, frequency of repeat procedures, and trends in open (arthrotomy) versus closed (arthroscopy) TMJ surgery. Data on 194 TMJ surgical procedures was extracted from line item claims information collected by Trigon Blue Cross/Blue Shield of Virginia. The frequency of arthroscopy increased during the study, while the incidence of arthrotomies remained relatively low. Approximately half of the hospitals statewide did not perform either procedure. There was a low frequency (3%) of repeat procedures. In the Commonwealth of Virginia, since the advent of TMJ arthroscopy, it has become the preferred surgical technique for treatment of internal derangement. There is a low incidence of repeat procedures for both types of treatment. Analysis of insurance carrier computer records is a valid technique for evaluating trends in surgical care.

Diagnosis, complications, and treatment of dentoskeletal malocclusion.

The frequency of correctable malocclusion makes it imperative that the condition be diagnosed and referred for appropriate treatment. A complete dentofacial examination, which assesses facial symmetry and the dentition in the transverse, sagittal, and centric relations, is appropriate. Early diagnosis is imperative because malocclusion leads to long-term complications such as temporomandibular joint (TMJ) dysfunctions, perodontal disease, obstructive sleep apnea, psychological disorders, and articulation errors. A combination of orthodontic treatment and orthognathic surgery will correct the dentoskeletal malocclusion and prevent any long-term complications. The purpose of this case report is to describe a patient with severe dentoskeletal malocclusion who benefitted from appropriate orthodontic treatment and orthognathic surgery.

A new computerized control unit for small bone surgical instruments.

The SmartDrive console represents an important advance in small bone surgery because it monitors and coordinates the operation of its handpieces. The SmartDrive console has the following unique features: 1) a handpiece recognition system; 2) an instrument speed display; 3) a handpiece display and monitoring system; 4) a torque instrument control system; 5) a temperature monitoring system; 6) and an irrigation system. Mechanical performance studies have been undertaken that have validated the accuracy of the monitoring systems of the consoles. The consoles provided reliable recordings of the rotational speeds of their hi-speed drills. The MicroAire console automatically shuts off its power as the temperature increased to 110 degrees F (43 degrees C). In contrast, the Stryker Command 2 console has a limited monitoring system that can not alter the operation of the handpieces.