Telemedicine in OMFS: a literature review of its potential and future prospects.

In the backdrop of telemedicine's rise, this review explores its integration into oral and maxillofacial surgery (OMFS), especially given the healthcare access challenges faced by nearly 20% of the rural population in the United States of America. The study underscores the potential of telemedicine to address disparities in access to OMFS care, particularly in rural areas, by improving patient care, reducing travel needs, and fostering collaborative diagnosis and treatment. The findings advocate for broader adoption of telemedicine in OMFS, contingent upon supportive policy and infrastructure changes.

A comparative review of epinephrine and phenylephrine as vasoconstrictors in dental anesthesia: exploring the factors behind epinephrine's prevalence in the US.

This review paper delves into the comparative study of epinephrine and phenylephrine as vasoconstrictors in dental anesthesia, exploring their histories, pharmacological properties, and clinical applications. The study involved a comprehensive literature search, focusing on articles that directly compared the two agents in terms of efficacy, safety, and prevalence in dental anesthesia. Epinephrine, with its broad receptor profile, has been a predominant choice, slightly outperforming in the context of prolonging dental anesthesia and providing superior hemostasis, which is crucial for various dental procedures. However, the stimulation of beta-adrenergic receptors caused by epinephrine poses risks, especially to patients with cardiovascular conditions. Phenylephrine, a selective alpha-1 adrenergic agonist, emerges as a safer alternative for such patients, avoiding the cardiovascular risks associated with epinephrine. Moreover, its vasoconstrictive effect may not be as deleterious as that of epinephrine, due to its selective action. This review reveals that despite the potential benefits of phenylephrine, epinephrine continues to dominate in clinical settings, due to its historical familiarity, availability, and cost-effectiveness. The lack of commercially available pre-made phenylephrine dental carpules in most countries, except Brazil, and a knowledge gap within dental academia regarding phenylephrine, contribute to its limited use. This review concludes that while both agents are effective, the choice between them should be based on individual patient conditions, availability, and the practitioner's knowledge and familiarity with the agents. The underuse of other vasoconstrictors like levonordefrin and the unavailability of phenylephrine in pre-mixed dental cartridges in many countries highlights the need for further exploration and research in this field. Furthermore, we also delve into the role of levonordefrin and examine the rationale behind the exclusion of phenylephrine from commercially available pre-mixed local anesthetic carpules, suggesting a need for a responsive approach from pharmaceutical manufacturers to the distinct needs of the dental community.

Emergency protocol in the dental clinic: Assessing medical emergency training requirements and guidelines for dentists.

BACKGROUND: Medical emergencies are an unavoidable reality affecting dental practices. This review synthesizes and examines the guidelines offered by governmental and professional organizations. TYPES OF STUDIES REVIEWED: Licensing agencies and professional associations were chosen as organizations of focus based on legal authority, high professional regard, or both. International and interprofessional organizational counterparts were chosen as points of comparison. In total, 11 organizations were examined. Guidelines reported were compiled by examination of documents published on official agency websites and in associated peer-reviewed journals. RESULTS: Guidelines for the handling of medical emergencies in the dental clinic vary in level of detail and scope among sources. Licensing agencies provide basic requirements for training, encouraging oral health care providers to develop and integrate their own emergency response plans. Professional associations provide extensive detail on instruction in medical emergency management. Both licensing agencies and professional associations provide lists of emergency medications and equipment, with varying levels of instruction on drug maintenance and organization. Professional associations emphasize regular review of training and office emergency drills. CONCLUSION: Oral health care professionals are provided with basic and required elements of medical emergency training by licensing agencies. They may seek out recommended, but not required, instruction from professional associations. Although guidance is provided, literature on protocol instituted in dental practices is limited. Further research is necessary to determine the oral health care community's approach to emergency management. PRACTICAL IMPLICATIONS: Providers must be prepared to handle medical emergencies that they encounter. Accessible and understandable guidelines are crucial to safe dental practice.

Is Penicillin Allergy a Risk Factor for Surgical Site Infection After Oral and Maxillofacial Surgery?

PURPOSE: The selection of perioperative antibiotics for prevention of surgical site infection (SSI) is often limited by the presence of a reported penicillin allergy. The purpose of this study was to determine if oral and maxillofacial surgery patients who report allergy to penicillin are at an increased risk of developing SSI. METHODS: A retrospective cohort study was performed of patients who underwent oral and maxillofacial surgical procedures in the operating room setting at a single institution between 2011 and 2018. The following categories of procedures were investigated: dentoalveolar, orthognathic, orthognathic with third molar extraction, pathology and reconstruction, and temporomandibular joint. The primary predictor and outcome variables were reported penicillin allergy and surgical site infection, respectively. Bivariate and multiple logistic regression analysis were performed. P < .05 was considered to be significant. RESULTS: The cohort was composed of 2,058 patients of which 318 (15.5%) reported allergy to penicillin. Beta-lactam antibiotics were administered less frequently to penicillin allergic patients perioperatively compared with those without penicillin allergy (7.9 vs 97.1%, P < .001), while clindamycin was more commonly administered (76.4 vs 2.5%, P < .001). Clindamycin was associated with a higher SSI rate compared with beta-lactam antibiotics (5.6 vs 1.4%, P < .001). Penicillin allergy was significantly associated with SSI at an adjusted odds ratio of 2.61 (95% CI 1.51 to 4.49, P = .001). After holding perioperative antibiotic usage equal between the 2 groups, penicillin allergy per se was no longer associated with SSI (P = .901), suggesting that the outcome was mediated by antibiotic selection. CONCLUSIONS: Penicillin allergy was associated with development of SSI due to receipt of non-beta-lactam antibiotics as perioperative prophylaxis. Formal allergy evaluation should be considered for patients with putative penicillin allergy.

Interaction analysis of risk factors for long-term skeletal relapse following mandibular advancement with bilateral sagittal split osteotomy.

The aim of this study was to identify interaction effects among risk factors for long-term skeletal relapse. The study sample consisted of 96 patients who underwent mandibular advancement with bilateral sagittal split osteotomy. Ten predictor variables were analyzed for an interaction effect: sex, age, preoperative temporomandibular joint symptoms, mandibular plane angle (MPA), single or double jaw surgery, clockwise or counterclockwise mandibular rotation, magnitude of mandibular advancement, concomitant genioplasty, type of fixation, and follow-up duration. Modeling interactions between pairs of covariates were applied to detect a significant interaction among these risk factors on horizontal and vertical long-term skeletal relapse, respectively. Stratification analyses and two-way full factorial interaction analyses were performed to demonstrate how the interaction influenced the associations between covariates and relapse. The interactions between sex and mandibular rotation (P=0.006) and between MPA and mandibular rotation (P=0.002) were statistically significant for horizontal long-term skeletal relapse. No significant interaction was identified for vertical relapse. This study showed that female patients and those with an MPA ≥30° undergoing counterclockwise mandibular rotation are predisposed to greater horizontal long-term skeletal relapse. Therefore, the judicious use of counterclockwise rotation is recommended in order to minimize the relapse, especially in female patients and those with a high MPA.

Do Patients With Different Mandibular Plane Angles Have Different Time to Relapse After Bilateral Sagittal Osteotomy With Mandibular Advancement?

PURPOSE: This study sought to answer the following question: Do patients with different mandibular plane angles (MPAs) have a different time to relapse after mandibular advancement with bilateral sagittal split osteotomy? MATERIALS AND METHODS: We performed a retrospective cohort study of patients who underwent bilateral sagittal split osteotomy advancement at Massachusetts General Hospital between 2005 and 2017. The primary predictor variable was MPA, categorized as low (<25°), medium (between 25° and 35°), or high (>35°). The outcome variable was time to relapse (≥2-mm posterior change at the B point). Other covariates included gender, age, temporomandibular joint symptoms, bimaxillary surgery, direction of mandibular rotation, magnitude of advancement, genioplasty, and fixation method. Time to relapse was estimated using the Kaplan-Meier method. Cox and parametric regressions for interval-censored data were performed. P < .05 was considered statistically significant. RESULTS: The sample was composed of 58 patients (40 female patients), with a mean age of 26.1 ± 4.9 years, grouped as follows: low MPA, n = 15; medium MPA, n = 26; and high MPA, n = 17. Clinically significant relapse was found in 18 patients (31%). Age, temporomandibular joint symptoms, counterclockwise rotation, and magnitude of advancement were statistically significantly different among the 3 groups. When we assessed time to relapse, the Kaplan-Meier method showed that high-MPA patients had a longer mean time at risk and higher estimated probabilities of relapse at different time points compared with low- and medium-MPA patients (P < .05). However, this association was not significant in Cox and parametric regressions. CONCLUSIONS: Our results suggest that clinically significant relapse was found during the first postoperative year in low-MPA patients and from 2 to 5 years postoperatively in high-MPA patients. Multivariate regression analyses did not show a significant association between MPA and time to relapse, suggesting that other covariates may play a role in the observed time to relapse.

Cricothyroid Membrane Puncture-Guided Tracheostomy: A New Technique for Emergency Airway Access.

PURPOSE: We sought to compare cricothyroid membrane puncture-guided tracheostomy (CMPGT) with surgical cricothyroidotomy (SC) and percutaneous tracheostomy with Griggs' guidewire dilating forceps (GWDF) for establishing an emergency airway in a porcine model. We hypothesized that CMPGT would be associated with a shorter time to ventilation and more rapid restoration of oxygenation. MATERIALS AND METHODS: We implemented a small pilot animal study. Eighteen miniature pigs were randomly assigned to undergo CMPGT, SC, or GWDF. The predictor variable was the technique used. The primary outcome variable was time to ventilation. Other outcome variables were efficiency of oxygenation restoration, procedure duration, and procedure-related complications. The data were assessed using 1-way analysis of variance and Bonferroni correction. The oxygen saturation (SpO2) changes over time were graphed using a time-series line plot. Statistical significance was set at P < .05. RESULTS: Airways were successfully established in all 18 pigs. SC (68 ± 4 seconds) showed the shortest procedure duration compared with GWDF (95 ± 3 seconds) and CMPGT (96 ± 4 seconds); however, the time to ventilation using CMPGT (21 ± 2 seconds) was significantly shorter than that with SC (68 ± 4 seconds) and GWDF (95 ± 3 seconds) (P < .01). Spo2 in each group increased postoperatively, reaching 95% at 120 seconds, 131 seconds, and 144 seconds in the CMPGT, SC, and GWDF groups, respectively. The slope of the ascending phase of the Spo2 curve was 0.38 for CMPGT, 0.42 for SC, and 0.53 for GWDF (P < .05). Two pigs in each group had minor intraoperative bleeding, and 1 pig in the SC group had moderate bleeding. CONCLUSIONS: The results of this animal study suggest that CMPGT is a time-efficient and safe technique for emergency airway access that allows for a more rapid return of ventilation and obviates conversion to definitive tracheostomy. Further cadaveric study is ongoing.

SMCHD1 mutations associated with a rare muscular dystrophy can also cause isolated arhinia and Bosma arhinia microphthalmia syndrome.

Arhinia, or absence of the nose, is a rare malformation of unknown etiology that is often accompanied by ocular and reproductive defects. Sequencing of 40 people with arhinia revealed that 84% of probands harbor a missense mutation localized to a constrained region of SMCHD1 encompassing the ATPase domain. SMCHD1 mutations cause facioscapulohumeral muscular dystrophy type 2 (FSHD2) via a trans-acting loss-of-function epigenetic mechanism. We discovered shared mutations and comparable DNA hypomethylation patterning between these distinct disorders. CRISPR/Cas9-mediated alteration of smchd1 in zebrafish yielded arhinia-relevant phenotypes. Transcriptome and protein analyses in arhinia probands and controls showed no differences in SMCHD1 mRNA or protein abundance but revealed regulatory changes in genes and pathways associated with craniofacial patterning. Mutations in SMCHD1 thus contribute to distinct phenotypic spectra, from craniofacial malformation and reproductive disorders to muscular dystrophy, which we speculate to be consistent with oligogenic mechanisms resulting in pleiotropic outcomes.

The whole is more than the sum of its parts: Aristotle, metaphysical.

This phrase, a favorite of Dr. Joseph E. Murray, can be interpreted in many ways. Mathematically, the whole is equal to the sum of its parts, neither more nor less. Psychological Gestalt theory would maintain that the whole is something else or something different than the sum of its parts. Merely adding up the component parts is meaningless compared with the "part-whole" relationship (SYNERGETICS: Explorations of Thinking. MacMillan Publishing Co, Inc; 1975). Organizational pundits maintain that this principle describes the synergy, which exists between individuals working together in a cooperative effort. Collectively, they are able to achieve an outcome superior to that of 1 or 2 people working alone. This concept is vintage Joseph E. Murray. He was an integral part of the Peter Bent Brigham team, which transformed the dream of organ transplantation into clinical reality over 50 years ago. Although many advances in medicine are made by the serendipity of a prepared mind making a critical observation (Alexander Fleming and penicillin), individual brilliance (Judah Folkman and angiogenesis), or by technology (magnetic resonance imaging), most are achieved by groups of physicians and scientists working together. All have prepared minds. When the Peter Bent Brigham Hospital physicians and researchers at the Harvard Medical School dedicated all of their energy on solving the problems of end-stage renal disease, their effort was concentrated and primarily regional. Today, this cooperation is global, as communication has been facilitated by the Internet, iPhone, iPad, video conferencing, electronic libraries, and the like.

The presentation and management of mandibular tumors in the pediatric population.

OBJECTIVES/HYPOTHESIS: To review the presentation and management of malignant tumors of the mandible in children. STUDY DESIGN: Case series. METHODS: Children 0 to 21 years old presenting to a tertiary pediatric hospital with a diagnosis of a malignant tumor involving the mandible were included. Comparison groups included children from the Surveillance, Epidemiology, and End Results database with malignant mandible tumors as well as a group of children with benign mandibular lesions from the same institution. Main outcome measures for the institutional malignant group included presentation, tumor characteristics, treatment modalities, and clinical outcome. RESULTS: Sixteen patients with malignant and 183 patients with benign lesions were identified at the primary institution. The most common presentation in both groups was mandibular swelling or mass. Malignant tumors included sarcoma (n = 11), leukemia/lymphoma (n = 2), squamous cell carcinoma (n = 1), malignant spindle cell tumor (n = 1), and yolk sac tumor (n = 1). The national database identified 56 malignant cases, of which 71% were sarcomas. Thirteen patients at our institution (81%) underwent mandibulectomy and 12 were reconstructed using free tissue transfer. Eleven of the 13 (85%) were treated with adjuvant therapy. After an average follow-up of 32.8 months, seven (44%) had no evidence of disease, three (19%) were deceased, three (19%) were alive with disease, and three (19%) were lost to follow-up. CONCLUSIONS: Malignant mandibular tumors in children are most often sarcomas but can include other rare lesions. Free flap reconstruction is a reasonable option for even very young children requiring extensive mandibular surgery.

Reconstruction of pediatric cranial base defects: a review of a single microsurgeon's 30-year experience.

BACKGROUND: For the past 30 years, microsurgical free tissue transfer has enabled the reconstruction of pediatric cranial base lesions formerly believed to be refractory to surgical therapy. Due to the relative rarity of these oncologic processes and the highly specialized requirements for their treatment, few large-scale reviews of microsurgical reconstruction of pediatric cranial base lesions have been published to date. METHODS: A review of all free tissue transfer reconstructive procedures undertaken by a single microsurgeon for pediatric cranial base defects was performed for operations occurring between 1977 and 2007. All procedures were performed at a single institution on patients ranging from infancy to 16 years of age. Data were culled from a combination of patient charts, hospital records, radiographic studies, and clinical photographs. RESULTS: Thirty patient charts were analyzed from the defined 30-year period. The average patient age at the time of diagnosis was 5.3 years (SD = 4.9 years). The most common primary diagnosis was rhabdomyosarcoma (n = 10; 33%). Most patients received chemotherapy (n = 26; 87%) or radiotherapy (n = 16; 53%). Most patients required extirpative hemimaxillectomy or hemimandiblectomy, necessitating reconstruction of intraoral structures in 16 children (53%). Forty free tissue transfers were performed; the most commonly used donor site was the rectus abdominis muscle (n = 19; 48%), followed by the fibula (n = 13; 30%), scapula (n = 5; 13%), latissimus dorsi muscle (n = 2; 5%), and radial forearm (n = 1; 3%). Reconstructive adjuncts included nonvascularized bone grafts (n = 13; 43%) and sural nerve grafts (n = 6; 20%). Short-term perioperative complications were relatively minor; no flap losses were recorded. The most common anticipated long-term complications included growth disturbances (n = 10; 33%), resorption of nonvascularized bone grafts (n = 8; 27%), and soft tissue atrophy/contracture (n = 8; 27%). Most patients studied were noted to be surviving (n = 22; 73%), with an average age of 19.2 years (SD, 10.1 years); among those patients who had died (n = 8; 27%), the average age at death was 14.6 years (SD, 6.2 years). The preponderance of patients who had died received their initial surgery and reconstruction during the first 15 years of this study period (n = 7; 88% of subgroup), with death most often due to complications related to extension of the original malignancy through the cranial base. CONCLUSIONS: As advances in oncologic therapy continue to improve survival among pediatric patients experiencing malignancies involving the cranial base, microsurgery simultaneously continues to enable robust options for postextirpative reconstruction and therefore provides a major benefit to the ongoing care of these individuals.

Vascularized fibular graft for pediatric mandibular reconstruction.

BACKGROUND: Although vascularized bone grafts have become well accepted in adults, especially following ablative head and neck procedures, there are few long-term reports of their use in pediatric patients. METHODS: In this study, the authors analyzed the outcomes of 18 free fibula grafts in 16 patients aged 10 months to 21 years (mean, 12 years) with an average follow-up of 5 years. Eleven patients had cancer-related defects, four had craniofacial anomalies, and one had a posttraumatic deformity. All patients with congenital malformations had been followed since birth, and the others had been followed from the time of their original cancer diagnosis or injury. RESULTS: Of the 16 patients, seven underwent irradiation and seven underwent chemotherapy. The most severe deformities were seen in those with cancer resection and radiation therapy. Most defects were hemimandibular; there was one total mandibular defect (a child with Ewing sarcoma). Ten patients had had previous failed nonvascularized bone grafts. Eleven flaps were osteocutaneous with either intraoral or extraoral components; most had multisegmental osteotomy and had one arterial and two venous anastomoses. All free fibula transfers were successful; there were no vascular problems and only two minor complications. CONCLUSION: A number of lessons are learned from careful analysis of this unique group of patients, and an algorithm of pediatric mandibular reconstruction is proposed.

Smaller mandibular size in infants with a history of an apparent life-threatening event.

OBJECTIVES: To examine small mandibular size and preference for a hand-to-chin posture as salient characteristics in infants with a history of an apparent life-threatening event (ALTE). STUDY DESIGN: This was a prospective case-control study of term infants, from birth to 6 months of age, admitted post-ALTE and matched 1:2 with healthy control infants (age within 2 weeks and weight within 0.5 kg). Infants with confirmed gastroesophageal reflux and congenital anomalies, including severe micrognathia, were excluded. RESULTS: Infants with a history of an ALTE (n = 25) were matched to 47 healthy controls. Infants with a history of an ALTE had mandibular indices (larger index indicates a smaller mandible) that were 3.8 mm greater on the left side (95% CI: 2.0-5.6, P < .001) and 4.2 mm greater on the right side (95% CI: 2.7-5.6, P < .001) adjusting for length and non-white race. Controlling for matching and length, a 1-mm increase in the average mandibular index increased the odds of an ALTE by 62% (OR = 1.62, 95% CI: 1.22-2.44, P < .001). CONCLUSIONS: Smaller mandibular size was associated with ALTE, suggesting airway obstruction as a potential cause of ALTE. The association of this characteristic with ALTE also offers the potential for prospective quantification of ALTE risk.

Lymphatic malformation of the lingual base and oral floor.

BACKGROUND: Lymphatic malformation of the tongue and floor of the mouth is associated with chronic airway problems, recurrent infection, and functional issues related to speech, oral hygiene, and malocclusion. There are no accepted anatomic guidelines or treatment protocols. METHODS: This retrospective review focused on anatomic extent, treatment, complications, and airway management in 31 patients with lymphatic malformation of the lingual base and oral floor. RESULTS: Involved adjacent structures included the neck (77 percent), mandible (41 percent), face (42 percent), lips (10 percent), pharynx (45 percent), and larynx (26 percent). Fifty-eight percent of patients required tracheostomy during infancy; decannulation was possible in two-thirds of these patients. Management included resection alone (42 percent), resection and sclerotherapy (26 percent), resection and laser coagulation (16 percent), sclerotherapy and laser coagulation (16 percent), and resection and radiofrequency ablation (3 percent). Resection involved the neck (58 percent), floor of the mouth (52 percent), and tongue (42 percent); there were often multiple procedures. Aspiration was tried with little success in 10 percent of patients. Virtually all patients had residual abnormal lymphatic tissue. Complications and posttherapeutic problems included infection (81 percent), neural damage (27 percent), difficulty in speech (23 percent), feeding problems (10 percent), and seroma or hematoma (6 percent). Associated dental/orthognathic conditions, particularly prognathism and anterior open bite, were documented in one-third of patients. CONCLUSIONS: The initial step in the protocol is control of the neonatal airway. Staged cervical resection is undertaken in late infancy to early childhood; resection should also include abnormal tissue in the oral floor. Sclerotherapy is primarily for macrocystic disease or secondarily for recurrent cysts following partial extirpation. Vesicles of the mucous membranes and dorsal tongue are treated either by sclerotherapy, laser (carbon dioxide, yttrium-aluminum-garnet, or potassium-titanyl-phosphate), or radiofrequency ablation. Reduction for macroglossia is indicated for persistent protrusion or to allow correction of malocclusion. Embolization controls lingual bleeding. Orthognathic procedures are undertaken at the appropriate age, only after lingual size and position are acceptable.