A Systematic Review and Meta-Analysis Comparing Surgical and Nonsurgical Treatments for Excessive Gingival Display.

Excessive gingival display (EGD) is defined as more than 2 mm of gingiva display above the maxillary incisors at maximum smile. Various skeletal, dental, and soft tissue etiological factors for EGD have been suggested. This study assessed the effectiveness and stability of surgical (SX) and nonsurgical (NSX) interventions for correction of EGD through a systematic review and meta-analysis following PRISMA 2020 guidelines. An electronic search of Ovid MEDLINE, EMBASE, CENTRAL, Scopus, Web of Science, and LILACS was conducted (2010-2023). Results were expressed as mean change in gingival display using the random-effects model at 1, 3, 6, and 12-month follow-up. At 1 month, SX and NSX treatments yielded a comparable mean reduction of 3.50 mm (2.13-4.86) and 3.43 mm (2.67-4.19) in gingival display, respectively. However, by 6 months, NSX treatments showed a reduction of 0.51 mm compared to 2.86 mm with SX treatments. SX outcomes remained stable past 6 months, while NSX outcomes partially relapsed at 6 months and returned to baseline levels at 12 months. Notably, NSX treatments were more effective in cases with mild initial EGD, while SX treatments showed a better outcome in severe cases. To draw more robust conclusions regarding the treatment outcomes, future primary studies of greater rigor are required.

Retention Strategies for Segmental Lefort I Osteotomies Using Clear Aligners.

Clear aligner therapy is becoming a mainstay of contemporary orthodontic treatment. As such wide-spread adoption and case-selection for surgical-orthodontic treatment in patients with Clear aligner therapy is increasing. Passive aligners generally lack adequate rigidity for retention of segmental movements in the immediate postoperative period. In this report we discuss our techniques for maintaining retention in the weeks after segmental maxillary osteotomies by use of a modified clear aligner orthognathic splint, and a custom palatal horseshoe splint, including the relative indications of each method.

Presurgical orthodontic decompensation with clear aligners.

INTRODUCTION: Orthodontists, surgeons, and patients have taken an interest in using clear aligners in combination with orthognathic surgery. This study aimed to evaluate the accuracy of tooth movements with clear aligners during presurgical orthodontics using novel 3-dimensional superimposition techniques. METHODS: The study sample consisted of 20 patients who have completed presurgical orthodontics using Invisalign clear aligners. Initial (pretreatment) digital dental models, presurgical digital dental models, and ClinCheck prediction models were obtained. Presurgical models were superimposed onto initial ones using stable anatomic landmarks; ClinCheck models were superimposed onto presurgical models using surface best-fit superimposition. Five hundred forty-five teeth were measured for 3 angular movements (buccolingual torque, mesiodistal tip, and rotation) and 4 linear movements (buccolingual, mesiodistal, vertical, and total scalar displacement). The predicted tooth movement was compared with the achieved amount for each movement and tooth, using both percentage accuracy and numerical difference. RESULTS: Average percentage accuracy (63.4% ± 11.5%) was higher than in previously reported literature. The most accurate tooth movements were buccal torque and mesial displacement compared with lingual torque and distal displacement, particularly for mandibular posterior teeth. Clinically significant inaccuracies were found for the buccal displacement of maxillary second molars, lingual displacement of all molars, intrusion of mandibular second molars, the distal tip of molars, second premolars, and mandibular first premolars, buccal torque of maxillary central and lateral incisors, and lingual torque of premolars and molars. CONCLUSIONS: Superimposition techniques used in this study lay the groundwork for future studies to analyze advanced clear aligner patients. Invisalign is a treatment modality that can be considered for presurgical orthodontics-tooth movements involved in arch leveling and decompensation are highly accurate when comparing the simulated and the clinically achieved movements.

Reconstruction of Large Defects Using Extended Temporomandibular Joint Patient-Matched Prostheses.

PURPOSE: Custom temporomandibular joint (TMJ) prostheses are useful in reconstructing large defects following TMJ resection. The purpose of this study is to evaluate the feasibility of extended-temporomandibular joint replacement (e-TJR) for reconstructing these defects. METHODS: This is a single-group retrospective cohort study that enrolled patients having received an e-TJR between January 2004 and November 2019 at the University of Toronto. The primary outcome variable was a change in maximal interincisal opening (MIO) following reconstruction with an e-TJR, while the secondary outcome variables were changes in pain and quality of life following surgery. The investigators also documented the frequency and types of postoperative complications. Multivariate linear regressions were conducted and were considered significant at P < .05. RESULTS: The sample was composed of 17 patients (10 unilateral and 7 bilateral joint replacements). The mean age of those included was 44.0 years (standard deviation [SD] = 18.6), and 11 (65%) were female. The median follow-up time was 32 months. Starting at a baseline mean MIO of 28.8 mm (SD = 15.4), the mean MIO increased slightly to 35.2 mm (SD = 7.1) after e-TJR (P = .10). Similarly, mean pain scores decreased from 4.0 (SD = 4.0) to 1.0 (SD = 1.3), and mean quality of life scores improved from 0.50 (SD = 0.29) to 0.86 (SD = 0.10) following surgery (P = .007 and P = .001, respectively). No mechanical failures or catastrophic infections were observed. CONCLUSIONS: This initial study supports the e-TJR for the reconstruction of large TMJ and maxillofacial defects. Further high-quality studies are required to confirm these findings.

Provision of Government-funded and Pro Bono Dental Care: Are There Gender Differences?

BACKGROUND: Government-funded and pro bono dental care are important to populations with limited means. At the same time, dentistry is experiencing a gender shift in the practising profession. As a result, we aimed to determine the factors associated with the provision of government-funded and pro bono dental care and whether there are gender differences. METHODS: We conducted a secondary data analysis of the results of a 2012 survey of a representative sample of Ontario dentists. Descriptive, bivariate and multivariable analyses were carried out. RESULTS: The 867 survey respondents represented a 28.9% response rate. On average, Ontario dentists reported that 15.7% of their practice consisted of government-funded patients and they provided $2242 worth of pro bono care monthly. Male and female dentists reported similar levels of both (p > 0.05). Being a practice owner and having more pediatric patients influenced levels of government-funded patients. Being internationally trained, of European ethnicity, single, and income status affected levels of monthly pro bono care. Gender-stratified analysis revealed that, among female dentists, household responsibilities was a unique factor associated with the proportion of government-funded patients, as was international training, personal income and ethnic origin for levels of pro bono care. CONCLUSION: Overall, male and female dentists are similar in the provision of government-funded and pro bono care, but various factors influence levels of each in both groups.

Alloplastic Temporomandibular Joint Replacement in Patients With Systemic Inflammatory Arthritis and Connective Tissue Disorders.

PURPOSE: We present a retrospective study to report the outcomes of total temporomandibular joint (TMJ TJR) replacement with alloplastic devices in patients suffering from systemic inflammatory arthropathies. METHODS: A total of 39 patients with a diagnosis of rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PA), juvenile idiopathic rheumatoid arthritis (JIA), or systemic lupus, underwent alloplastic total joint replacement(s) (TJR) from 1999 to 2019. Maximal interincisal opening (in mm) was recorded before surgery (T0), at 1-year post-surgery (T1) and at last follow-up (T2). A visual analog scale (from 0 to 10) was used for subjective examination of pain before surgery (T0) and at last follow-up (T2). Comparisons were conducted with statistical significance set at P < .05. RESULTS: Seventy-four joints were replaced in 39 patients. Thirty-two were female. The mean age was 36 years old (range 18-61) and the mean follow-up was 45.9 months (SD 49.4). The most common diagnosis was RA (n = 21), followed by JIA (n = 5) and AS (n = 5), PA (n = 4), lupus (n = 3), and mixed connective tissue disorder (n = 1). The mean pain score had fallen from 6.8 (SD 3.2) at T0 to 1.3 (SD 2.4) (P < .001) at T2. The maximal interincisal opening had improved from a mean of 22.1 mm (SD 13.3) at T0 to 34.3 mm (SD 8.5) (P < .001) at T2. One patient got persistent dysesthesia in the V3 distribution. There were no serious late complications. CONCLUSION: Patients suffering from systemic inflammatory arthropathies involving the TMJs can be successfully treated by TJR with alloplastic devices. The long-term reduction of TMJ symptoms and functional improvement in this initial study suggest good predictability for this treatment.

Public and Professional Perceptions of the Scope of Practice of Oral and Maxillofacial Surgeons.

PURPOSE: To investigate and compare the general public's, general dentists', and primary care physicians' level of knowledge of the scope of practice of oral and maxillofacial surgeons (OMSs). We hypothesized that there is a generalized lack of knowledge of the scope of practice of oral-maxillofacial surgery, with the general public being the least informed and the general dentists the most educated. METHODS: A cross-sectional survey study was conducted via a mail-out survey that was delivered to a random sample of the general public, general dentists, and primary care physicians in Ontario, Canada. A total of 1800 participants were selected. The survey consisted of a demographic screener along with 24 clinical scenarios in which the participants could select all the specialists they thought were capable of completing the treatment. Inferential statistics were computed using a chi-square test to compare responses between the groups and identified any significant differences between subjects for each of the 24 scenarios with P value set at 0.05. RESULTS: Total response rate of 50.1% (n = 902) was achieved. The majority of health professionals (100% dentists, 95.5% primary care physicians) have heard of oral-maxillofacial surgery, in contrast to only 73.7% of the general public (P < .001). There was a general lack of awareness of oral-maxillofacial surgery scope of practice by all groups wherein OMSs were selected less than 50% of the time in 10 (general dentists), 14 (primary care physicians), and 16 (general public) of 24 clinical scenarios. CONCLUSION: Greater than 25% of the general public are unaware of OMS. More concerning, the general public and health professionals as a whole are unfamiliar with the full scope of practice of OMSs. For enhancing access to care by qualified specialists, educational programs highlighting key aspects of oral-maxillofacial surgery should be developed and distributed to all populations.

5-Fluorouracil Is Associated With a Decreased Recurrence Risk in Odontogenic Keratocyst Management: A Retrospective Cohort Study.

PURPOSE: The antimetabolite drug, 5-fluorouracil (5-FU), has been suggested as an adjunctive treatment to reduce the recurrence rates of odontogenic keratocysts (OKCs). We report on the use of 5-FU in the management of patients with OKCs as a postenucleation intracavity topical dressing. METHODS: For this retrospective cohort study, we collected all data of sequentially treated cases presenting to the University of Toronto's hospital clinics for the management of biopsy-proven OKCs. Chart reviews were conducted to identify all patients treated with 5-FU cream, and compare them to patients treated with modified Carnoy's solution (MCS). In the treatment group, all patients were treated in an identical manner with enucleation and peripheral ostectomy followed by the application of 5% 5-FU cream for 24 hours. Preoperative and postoperative radiographs were collected to determine the time to recurrence of the disease, and the techniques were compared via a multivariate Cox regression analysis. RESULTS: Seventy patients were found to be eligible for inclusion in this study. Of these, 34 patients were treated with 5% topical 5-FU, and 36 patients were managed with MCS. The median follow-up time in the 5-FU group was 22 months (interquartile range, 36), compared with 27 months (interquartile range, 37) for the MCS group (P = .40). No recurrences were identified in the 5-FU group, compared with 9 recurrences (25%) in patients treated with MCS. 5-FU was shown to be significantly negatively associated with time to disease resolution (P < .01). CONCLUSIONS: Results from this study suggest that when used topically, 5-FU effectively lowers the recurrence rates of OKCs. Further large scale, case-controlled studies are being investigated at our center and are warranted to make definitive conclusions regarding the effectiveness of this novel technique when compared with conventional therapies.

Surgical uprighting of mandibular second molars: A single-group retrospective cohort study.

INTRODUCTION: The management of impacted, unerupted, or malpositioned mandibular second molars with orthodontic therapy requires special attention in order to achieve normal anatomic positioning within the dental arch. We present a surgical approach to managing these teeth combining exposure and surgically-assisted forced eruption. METHODS: This retrospective single-group cohort study followed 260 impacted mandibular second molars. The molars were exposed and surgically uprighted. An orthodontic bracket was bonded to aid in orthodontic traction, and the wound was packed to prevent soft tissue growth over the crown of the exposed molar. Patients were followed for a minimum of 6 months after uprighting, during which the following outcomes were measured: the degree of success of the eruption one the basis of the clinical occlusal relationship to the opposing dentition, radiographic evidence of bone fill, the periodontal status of the teeth involved, and tooth vitality. RESULTS: A total of 260 mandibular second molars were uprighted in 177 patients (83 female, 94 male) with an average age of 14.8 years. Outcomes showed that 255 molars (98.1%; 95% confidence interval, 96.3-99.8) were successfully uprighted. Complications included infection/abscess in 3 molars and fractured root requiring extraction in 2 molars. All remaining 255 teeth tested vital, 17 teeth had periodontal pocketing of more than 5 mm, and 235 of the teeth had occlusal contact after healing. CONCLUSIONS: Surgically-assisted forced eruption with or without orthodontic forced eruption is a safe, successful, and viable approach to managing unerupted or malpositioned mandibular second molars in the adolescent population.

Clear Aligner Orthognathic Splints.

Orthodontic treatment has been transformed by the introduction and overwhelming adoption of clear aligner therapy (CAT). Many patients are demanding esthetic and metal-free treatment alternatives, including those requiring orthognathic surgery (OGS), to correct their dentofacial deformities. The adoption of performing OGS for CAT has been cautious and challenging for many reasons. Intermaxillary fixation, postoperative occlusal control, preoperative decompensation management, and long-term stability need to be tested and assessed. This report presents an accurate 3-dimensional (3D) printed hard acrylic splint specifically for patients without any orthodontic attachment to be used in the positioning and fixation of osteotomized jaws. It is simple to manufacture and its use intraoperatively is efficient, straightforward, and accurate. This report introduces the Clear Aligner Orthognathic Splint for surgery and the steps required for 3D planning with recommendations for perioperative orthodontic support.

Primary aneurysmal bone cyst of the mandibular condyle with USP6-CDH11 fusion.

Primary aneurysmal bone cyst (ABC) is a cystic bone neoplasm characterized by disease-defining gene fusions involving the USP6/Tre2 gene. The literature describing gnathic ABC is limited. This case report describes a 27-year-old man presenting with a long-standing left-sided facial asymmetry. Multi-detector computed tomography imaging demonstrated a large expansile lesion positioned within the left condylar head. The lesion was biopsied and resected. The specimen showed a giant cell-rich cystic neoplasm, with fibrous tissue lined by multinucleated giant cells. Next-generation sequencing confirmed the presence of a USP6-CDH11 fusion gene, consistent with classification as a primary ABC, the first reported to be translocation-positive in the head of the mandibular condyle.

Novel Transoral Approach to the Posterolateral Maxilla and Infratemporal Region.

Surgical access to tumors involving the posterolateral maxilla and infratemporal region remains a considerable challenge for surgeons. Various surgical approaches for treating posterior maxillary lesions require transcutaneous incisions, such as an upper or lower cheek flap, but they often result in substantial morbidity. This article describes a novel transoral approach involving a curvilinear incision, temporalis myotomy, and coronoidectomy to allow direct visualization of the posterolateral maxilla and infratemporal region. This surgical technique may be used for the surgical resection of maxillary tumors that extend into the posterior maxillary sinus wall and pterygoid plate region via a transoral approach.

Topical 5-Fluorouracil is a Novel Targeted Therapy for the Keratocystic Odontogenic Tumor.

PURPOSE: The antimetabolite drug, 5-fluorouracil (5-FU), is used in the treatment of various cancers, including basal cell carcinomas (BCCs). The authors hypothesized that keratocystic odontogenic tumors (KOTs) would respond to 5-FU treatment because of their similarities to BCCs in molecular etiopathogenesis. MATERIALS AND METHODS: An ambispective cohort study of the treatment efficacy of topical 5-FU on KOTs was conducted. Independent variables included the topical application of 5% 5-FU or modified Carnoy's solution (MC) after enucleation and peripheral ostectomy at the University of Toronto from 2006 through 2014. Outcome variables included time to recurrence and peripheral nerve injury. KOT specimens in these patients were immunostained with p53, Ki-67, thymidylate synthetase (TS), thymidylate phosphorylase (TP), and dihydropyrimidine dehydrogenase (DPD) antibodies. Semiquantitative staining scores were calculated for all immunohistochemistry sections examined. Descriptive statistics were computed using Fisher exact test and Kaplan-Meier analysis as appropriate with the P value set at .05. RESULTS: Thirty-two patients with 32 KOTs were reviewed (41% in women and 59% in men). There were no KOT recurrences in the 5-FU group (n = 11), whereas there were 4 recurrences in the MC group (n = 21; P = .190). There was a significantly lower incidence of inferior alveolar nerve paresthesia with 5-FU treatment (P = .039). Immunohistochemical staining showed upregulation of TP (P < .0001) and DPD (P < .0001) and no change in TS (P > .05) in inflamed KOTs. CONCLUSIONS: 5-FU effectively treats KOTs with less postoperative morbidity than conventional treatment with MC. Low TS and upregulated TP expressions in inflamed KOTs suggest increased 5-FU efficacy in inflamed KOTs. Topical 5-FU is a novel therapy for KOTs and provides a targeted molecular approach to treatment.

Visual-spatial ability correlates with efficiency of hand motion and successful surgical performance.

BACKGROUND: This study examines the influence of visual-spatial ability and manual dexterity on surgical performance across 3 levels of expertise. METHODS: Dental students, surgical residents, and staff surgeons completed standardized tests of manual dexterity and visual-spatial ability and were assessed objectively while performing the rigid fixation of an anterior mandible on bench model simulations. Outcome variables included expert assessment of technical performance and efficiency of hand motion during the procedure (recorded using electromagnetic sensors). RESULTS: Visual-spatial scores correlated significantly with surgical performance scores within the group of dental students (r=.40 to.73), but this was not the case for residents or staff surgeons. For all groups, manual dexterity did not correlate with hand motion parameters. There were no differences between groups in visual-spatial ability or manual dexterity, but highly significant differences were seen in surgical performance scores (P<.001), in that surgeons outperformed residents, who in turn outperformed students. CONCLUSIONS: Among novices, visual-spatial ability is associated with skilled performance on a spatially complex surgical procedure. However, advanced trainees and experts do not score any higher on carefully selected visual-spatial tests, suggesting that practice and surgical experience may supplant the influence of visual-spatial ability over time. Thus, the use of these tests for the selection of residents is not currently recommended; they may be of more use in identifying those novice trainees (ie, those with lower test scores) who might benefit most from brief supplementary instruction on specific technical tasks.

Clinical success in harvesting autogenous bone using a minimally invasive trephine.

PURPOSE: Autogenous bone grafting is well established for use in the maxillofacial skeleton. We present our experience with minimally invasive bone harvesting using a power-driven trephine, with favorable patient and clinical results. MATERIALS AND METHODS: This retrospective study evaluation patients requiring autogenous bone harvested using a trephine, treated consecutively over a 3-year period. Mean patient age was 27.2 years (range, 8 to 77 years). Only those patients requiring elective surgery and admission on the same day were included in the study. Intraoperative assessment included the description of complications and the quantity and volume of the bone cores harvested. The complications monitored included bleeding, nerve injury, and perforation of the medial or lateral walls of the ilium. Postoperatively, patients were assessed for ambulation, pain, bleeding, and suitability for discharge. The patients were evaluated 1 week after surgery and were examined for wound complications (incision breakdown, infection, paresthesia, pain) and ambulatory deficits. All patients were then surveyed using a questionnaire outlining short-term (1 to 14 days), and long-term (>6 months postoperative) deficits, pain, and general remarks about the procedure. RESULTS: A total of 84 patients underwent bone harvesting using a power-driven trephine. Bone was harvested from a total of 86 anterior iliac crest sites, for a total of 333 cores (3.96 cores per patient). Forty-one patients were discharged on the day of surgery. Intraoperatively, the volume of bone obtained ranged from 3 to 21 mL per harvest site (1 to 7 cores, 4 mm x 30 to 38 mm). The bone volume obtained was dependent on the size of the defect to be filled. Intraoperatively, 1 complication occurred (1 of 333 cores; 0.3%)-a broken instrument-and there were no perforations of the medial or lateral walls of the ilium or excessive bleeding. The complications totaled 3 (3.6%); none of these produced long term effects. Patients surveyed up to 6 months postoperatively noted positive results. CONCLUSIONS: The harvesting of bone from the anterior iliac crest using a power driven trephine appears to be safe and results in minimal morbidity and ample bone volume for many maxillofacial procedures, without delaying discharge from hospital.

Life-threatening hemorrhage after extraction of third molars:case report and management protocol.

Few dental procedures have fatal complications, but severe postoperative hemorrhage can result in preventable death. This report describes a case of postextraction hemorrhage that led to airway compromise necessitating emergency airway management. This complication is rare, and a review of the literature revealed little in the way of case reports and treatment protocols. This article reviews the causes of and risk factors related to severe postoperative bleeding and presents an algorithm for management both in the dental office and in the hospital.