Late Outcomes of Undiagnosed Unilateral Condylar Hyperplasia and Reoccurrence of Mandibular Asymmetry.

Unilateral condylar hyperplasia (UCH) is a rare cause of asymmetrical mandibular overgrowth because of the presence of an atypical growth in the affected condyle. SPECT (single-photon emission computed tomography) can easily establish the presence of an atypical, prolonged growth exceeding far beyond normal condylar growth and activity. A CT, CBCT, or LDCT (computed tomography, cone-beam computed tomography, or low-dose computed tomography) can confirm the diagnosis by evaluating the scope of bone overgrowth, mandibular basis/ramus asymmetry, tendency to condylar head enlargement, changes in bone density, and occurrence of differences in condylar head shapes, size, and bone structure. In most cases, a condylectomy is the procedure of choice in growing cases of UCH to remove the pathological condyle and reduce asymmetry levels. Sometimes, the growth is very slow and progressive over time, causing slowly growing asymmetry with similar symptoms to any other mandibular asymmetry, and this causes some troublesome procedures in UCH diagnostics, resulting in patients being underdiagnosed; it can even lead to some relapses in mandibular asymmetry and skeletal malocclusion after previously performed orthodontic and surgical treatment of such discrepancies. When the source of asymmetry is not identified in time, possible inadequate treatment protocols can be used. If any relapse of facial and mandibular asymmetry re-occur, SPECT and CT evaluation are necessary to evaluate if condylar hyperplasia is present and to establish what kind of surgical intervention should be used in each case.

Methods of Definitive Correction of Mandibular Deformity in Hemimandibular Hyperplasia Based on Radiological, Anatomical, and Topographical Measurements-Proposition of Author's Own Protocol.

In order to fully evaluate and establish the degree of bone overgrowth, various radiological studies are essential in the careful planning of the amount of surgical excision. In the presented paper, the authors use self-designed anatomo-topographical reference points for planning the surgeries. Routine panoramic radiographs and low-dose computed tomography based on anatomical landmarks help in measuring the proportions of mandibular bone overgrowth with the following preoperative anatomical landmarks: (Go-Go), (Go(Right)-Gn), (Go(Left)-Gn), and (Me−Gn). Measurements taken at selected points and landmarks (gonion-gnathion/gnathion-menton) are easy to conduct. In the authors' proposal, the main key factor is total chin correction, which is necessary in cases of severe overgrowth; when F0 > C and Go-Gn>, there is >7 mm of vertical bone overgrowth, and the mandibular canal is positioned <5 mm from the inferior mandibular border­MIB. Larger overgrowths (>7 mm) have a greater outcome on the final symmetry than smaller overgrowths. As no guidelines are known, the authors present their own proposal.

Filler Migration and Florid Granulomatous Reaction to Hyaluronic Acid Mimicking a Buccal Tumor.

Hyaluronic acid is among the most commonly used cosmetic fillers. Although considered biocompatible and safe, it may rarely cause a wide range of complications. The authors report a case of migration of hyaluronic acid concomitant with granulomatous inflammatory response that mimicked a buccal tumor. A 52-year-old female presented with a solid painless mass of the right buccal area. The patient denied any history of trauma and cosmetic procedures of the affected area. Skin and mucosal membrane were intact and the lesion was firm and well fixed in the deep plane. Due to worrisome clinical presentation and the patient's history of breast cancer, the lesion was excised radically. Histopathological examination revealed multiple granulomas surrounding amorphous lakes of hyaluronic acid. During repeated, thorough anamnesis the patient admitted having underwent lip augmentation and nasolabial fold correction with HA two years before, after which the filler must have migrated posteriorly. Physicians need to be aware of various complications associated with cosmetic fillers as they may mimic severe clinical conditions.

Anatomical and Clinical Implications in Neocondyle Stability After a Condylectomy.

: A condylectomy of the mandibular condyle is considered to be the treatment of choice in most cases of condylar head hyperactivity. The aim of the procedure is to remove the growth center of the mandible which is responsible for the mandibular enlargement and asymmetry. This surgical procedure has an impact on the condyle shape and position, but the restoration of mandibular movement and a stable joint position (namely, the proper alignment of the newly shaped condylar head within the condyle fossa) should also be considered important surgical outcomes. In this article, the authors present their own experience in performing condylectomies with an arthroplasty procedure and a special forced suturing technique (FST) in terms of achieving early, accurate mandibular movement and maintaining a stable condyle position in early and late outcomes. MATERIALS AND METHODS: A modified high condylectomy with arthroplasty and FST results had been studied in anatomical, radiological, and clinical model. RESULTS: Early findings after FST are promising. A slight improvement in lateral jaw movement was noted after condylectomy with arthroplasty (P < 0.05) both in early and late follow-up. Incisal opening, mandibular protrusion, and lateral movement were sustained. A stable condyle position within the fossa was achieved in each case of condylectomy with arthroplasty (P < 0.05). CONCLUSIONS: The FST condylectomy and reattachment of the lateral pterygoid muscle in a new, wider position provided an improvement in lateral jaw movement as well as in incisal opening and mandibular protrusion in early follow-up examination compared to the presurgical values. It seems that the FST enabled a better new condylar head position in the glenoid fossa and improved early functional mandibular movement.

Ten years of observations and demographics of hemimandibular hyperplasia and elongation.

INTRODUCTION: The full epidemiology and etiology of hemimandibular hyperplasia (HH) has not yet been clarified. In most cases it starts before puberty and results in various forms of dento-alveolar and skeletal discrepancies. This study is the first attempt at evaluating and describing some of the authors' key experiences, clinical philosophical approach, and gathered demographic data on hemimandibular hyperplasia and hemimandibular elongation (HE) among the Polish population. MATERIAL AND METHOD: A total of 45 patients (M = 8; F = 37; p < 0.05) with HE (n = 16; 35.6%; p < 0.05), HH (n = 28; 62.2%; p < 0.05), or HH + HE (n = 1; 2.2%; p > 0.05) had been diagnosed and treated. Epidemiological, geographical, and clinical data concerning the occurrence and treatment protocols in these mandibular malformations were measured in the Polish study groups. RESULTS: Women more often suffered from these mandibular malformations (82-87%). The occurrence of the first symptoms was highest at the age of 13-15 years and was statistically significant for both sides (p < 0.05). The disorders were found earlier in young girls, therefore an early compensatory orthodontic treatment in some cases had been used with a limited degree of success (p > 0.05). All values of bone scintigraphy were significant (p < 0.001). CONCLUSIONS: A very fast growth with visible major asymmetry and enlarged condylar head should be an indication for condylectomy. Women's expectations from surgery and treatment are more demanding than men's, a fact that is connected with the predominance of females in the study group. Almost all possible treatment alternatives are not only related with the degree of skeletal deformity, but also with the patient's willingness to undergo any necessary treatment protocols, which in most cases involve more than one stage. Skeletal scintigraphy tests are an important factor in estimating bone growth and possible surgical approaches in these disorders.

Abdominal Retraction Pad Used in Orthognathic Surgery: A Novel Technique for Nasotracheal Tube Stabilization During Le Fort I Osteotomy.

Many types of surgical osteotomies of the cranio-facial skeleton relay on adequate surgical field preparation. Placement and stabilization of nasotracheal tube during orthognathic surgery is very important. In most cases, long-lasting surgery includes various surgical maneuvers around patient's skull, which depend on accurate nasotracheal tube stabilization. Usage of adhesive plasters for heavy anesthetic tube connector placement and stability might result in tube instability and local disfigurement of nasal projection and visibility in the nasal and infraorbital areas. We present a novel technique for nasotracheal tube stabilization allowing each surgeon controlling tube position, visual evaluation of nasal projection, and its tip during various surgical movements of maxillary bone, such as extrusion, intrusion, rotation or others, during Le Fort I osteotomy. Despite additional time necessary for preparation of surgical field, attachment of the tube and suturing, presented method allows achieving very satisfactory final outcomes with visible access to key nasal structures important in Le Fort I osteotomy. Presented method could be also used in any other facial surgery procedure.

The Lipomatosis of the Parapharyngeal and Retropharyngeal Space: A Case Report.

INTRODUCTION: Lipomas are the most common benign mesenchymal tumors, which account for almost 50% of all soft-tissue tumors. CASE OUTLINE: The case of a 75-year-old patient with a slow growing lesion of para- and retropharyngeal space was reported. The patient was suffering from progressive dysphagia, respiratory obstruction and sleep apnea. CONCLUSION: An external surgical approach is the treatment of choice. Etiology, differential diagnosis and therapy of head and neck lipomas has been discussed.

Stem cells and related factors involved in facial nerve function regeneration.

The facial nerve (VII) is one of the most important cranial nerves for head and neck surgeons. Its function is closely related to facial expressions that are individual for every person. After its injury or palsy, its functions can be either impaired or absent. Because of the presence of motor, sensory and parasympathetic fibers, the biology of its repair and function restoration depends on many factors. In order to achieve good outcome, many different therapies can be performed in order to restore as much of the nerve function as possible. When rehabilitation and physiotherapy are not sufficient, additional surgical procedures and therapies are taken into serious consideration. The final outcome of many of them is discussable, depending on nerve damage etiology. Stem cells in facial nerve repair are used, but long-term outcomes and results are still not fully known. In order to understand this therapeutic approach, clinicians and surgeons should understand the immunobiology of nerve repair and regeneration. In this review, potential stem cell usage in facial nerve regeneration procedures is discussed.

Primary hyperparathyroidism presenting as a giant cell tumor of the jaws.

OBJECTIVE: Giant cell tumors of the maxillofacial skeleton are uncommon, they are usually late manifestation of primary hyperparathyroidism. A series of five clinical cases in four women and one man presenting as the giant cell lesions in the maxilla and/or mandible are discussed. METHODS: Biopsy of the lesions, biochemical and hormonal analyses, densitometry and parathyroid scintigraphy were carried out. RESULTS: Biopsy of the lesions showed giant cell tumor of bone. The medical history and laboratory analyses showed primary hyperparathyroidism. Bone density loss was documented and scintigraphy revealed the presence of parathyroid adenomas in four cases. Surgical treatment of hyperparathyroidism, and in the second step - after 6-12 months - the subsequent excision of residual brown tumors in all cases was performed. CONCLUSIONS: One should have in mind that osteolytic bone lesions may be due to metabolic disease of the bone. Accurate diagnosis enabling the proper treatment should be carried out, avoiding unnecessary harm to the patients.

Clinical and radiological features of nonfamilial cherubism: A case report.

BACKGROUND: Cherubism is an uncommon hereditary benign fibro-osseous disorder characterized by bilateral enlargement of the mandible and the maxilla that presents with varying degrees of involvement and a tendency toward spontaneous remission. On radiography cherubic lesions appear as cystic multilocular radiolucencies limited to the jaw bones. CASE REPORT: A 5-year-old boy was referred to the Department of Maxillo-Facial Surgery due to deformation of the lower and middle section of the face and displacement or absence of teeth. A panoramic radiograph and a computed tomography revealed extensive multilocular, bilateral radiolucent areas and marked bony expansion in the mandible and maxilla, with sparing of the mandibular condyles. Histopathological evaluation of an incisional biopsy of the left maxilla and genotypic characterization confirmed the diagnosis of cherubism. CONCLUSIONS: The radiologic characteristics of cherubism are not pathognomonic but the diagnosis is strongly suggested by bilateral relatively symmetric jaw involvement that is limited to the jaw bones and, together with clinical and histopathologic findings, enables the diagnosis of cherubism. Genotypic characterization confirms the diagnosis.

Bisphosphonate-related osteonecrosis of the jaws: a review of 34 cases and evaluation of risk.

INTRODUCTION: The purpose of this study was to identify factors that influence bisphosphonate-related osteonecrosis of the jaws (BRONJ). PATIENTS AND METHODS: Patients undergoing treatment for BRONJ (n=34) were evaluated. Sex, age, underlying diagnosis, type of bisphosphonate (BP), duration and route of administration, location of osteonecrosis, clinical symptoms, Actinomyces colonisation, treatment and outcome were recorded. Symptom onset was analysed with respect to BP potency and cumulative dose. RESULTS: Underlying diagnoses indicating BP-treatment included multiple myeloma, breast carcinoma, prostate carcinoma and osteoporosis. In 31 patients, BRONJ was preceded by tooth extraction, root apicotomy, ill-fitting dentures, cystenucleation, implant insertion or trauma; in 3 patients, the precipitating event was not identified. Actinomyces colonisation was observed in 18 patients (53%). The occurrence of BRONJ was not directly related to BP dose or potency. More women with multiple myeloma had BRONJ than did males. BRONJ was observed in osteoporotic patients treated with both corticosteroids and BPs. CONCLUSIONS: BRONJ was not primarily associated with BP potency or dose. Factors that increased the risk of osteonecrosis were female sex, oral surgery and corticosteroids plus intravenous or oral BP administration. BP deposition in the jaw bones might enhance BRONJ by promoting bacterial colonisation; however, this hypothesis requires more study.

Multiple giant cell lesions in patients with Noonan syndrome and cardio-facio-cutaneous syndrome.

Noonan syndrome (NS) and cardio-facio-cutaneous syndrome (CFCS) are related developmental disorders caused by mutations in genes encoding various components of the RAS-MAPK signaling cascade. NS is associated with mutations in the genes PTPN11, SOS1, RAF1, or KRAS, whereas CFCS can be caused by mutations in BRAF, MEK1, MEK2, or KRAS. The NS phenotype is rarely accompanied by multiple giant cell lesions (MGCL) of the jaw (Noonan-like/MGCL syndrome (NL/MGCLS)). PTPN11 mutations are the only genetic abnormalities reported so far in some patients with NL/MGCLS and in one individual with LEOPARD syndrome and MGCL. In a cohort of 75 NS patients previously tested negative for mutations in PTPN11 and KRAS, we detected SOS1 mutations in 11 individuals, four of whom had MGCL. To explore further the relevance of aberrant RAS-MAPK signaling in syndromic MGCL, we analyzed the established genes causing CFCS in three subjects with MGCL associated with a phenotype fitting CFCS. Mutations in BRAF or MEK1 were identified in these patients. All mutations detected in these seven patients with syndromic MGCL had previously been described in NS or CFCS without apparent MGCL. This study demonstrates that MGCL may occur in NS and CFCS with various underlying genetic alterations and no obvious genotype-phenotype correlation. This suggests that dysregulation of the RAS-MAPK pathway represents the common and basic molecular event predisposing to giant cell lesion formation in patients with NS and CFCS rather than specific mutation effects.

Impact of tumour characteristic and treatment modality on the local recurrence and the survival in patients with oral squamous cell carcinoma.

PURPOSE OF THE STUDY: To evaluate the impact of tumour location, local and regional advancement, histological differentiation, status of the surgical margins and radiotherapy on the disease-free time and overall survival rates in patients with oral squamous cell carcinoma. MATERIAL AND METHODS: A retrospective analysis of 67 patients treated with surgery (61 pts.), radiotherapy (6 pts.) and their combination (28 pts.). Follow time on average 40 months. The probabilities of survival were assessed using the Kaplan-Meier estimates, the differences were calculated with the log-rank test. An analysis of the influence of the neck recurrences on the prognosis was additionally performed. Relationship between independent categorical variables as: primary local advancement, location of the tumour, histological grading and lymph node metastases was evaluated with Fisher's Exact Test. RESULTS: Disease-free time rate amounted to 40.1%. There was no independent prognostic importance of primary location, T-staging and N-staging, histological grading of the tumour or radiation on disease-free time, just opposite to the status of the resection margins. However, the number of neck metastases was directly proportional to the tumour dimension and poor histological differentiation. Overall survival rate amounted to 87,5%. Posterior location in the oral cavity, involvement of cervical lymph nodes, surgical margins with the presence of tumour cells, poor histological differentiation and necessity of irradiation negatively correlated with the survival. CONCLUSIONS: A complete resection of the tumour was the most important independent prognostic parameter for the disease-free and overall survivals in oral squamous cell carcinomas in this study. An adjuvant radiation therapy could improve the results of treatment of oral squamous cell carcinoma also in cases were so far considered only for surgical management.

Treatment of monostotic fibrous dysplasia with pamidronate.

INTRODUCTION: Fibrous dysplasia is a condition where fibrous tissue and bone with an altered structure replace normal bone. The craniofacial involvement is difficult to treat due to location, uncontrolled proliferation and compression of nerves. These result in facial asymmetry, pain, cranial nerve deficiencies, loss of vision or hearing, alterations in breathing, etc. The use of pamidronate, which inhibits the resorptive activity of osteoclasts may be an alternative to surgical intervention and may improve the results of treatment. AIM OF STUDY: To evaluate the treatment of monostotic craniofacial fibrous dysplasia with pamidronate. MATERIAL: A prospective pilot study was undertaken in 6 children with progressive fibrous dysplasia located in the mandible (3 pts), maxilla (2 pts) or cranial base (1 pt). Surgery consisted only of a biopsy and implantation of gentamycin sponge into the biopsy bed in 3 cases in which an infection was initially suspected. All patients received pamidronate infusions (1mg/kg i.v. for 3 days, every 4-6 months). The changes in bone density and extension of the disease were evaluated by serial orthopantomograms and CT scans. Follow up time was 9-24 months. RESULTS: Pain relief was achieved in all cases, decrease in swelling in 3, and stabilization in 3 cases. Radiological investigation revealed any progression but reduction in size and calcification of osteolytic lesions. The local bone density increased and there was no further spread of the disease in any of the patients. Inflammatory symptoms resolved in all cases. The only side effect was an increase in body temperature up to 38-40 degrees C. CONCLUSION: Pamidronate appears to be an effective and well-tolerated therapeutic option for patients with fibrous dysplasia. In the future, the combination of the metabolic blockage of the dysplasia by pamidronate and limited non-mutilating surgical interventions are possible.

Tissue reaction after implantation of Spongostan, as the carrier of xenogenic bone morphogenetic protein. Experimental study.

Reconstruction or filling of bone defects, especially in the maxillofacial region, often requires use of biomaterials. An implant should fasten healing of the bone gap or it should replace autogenic bone grafts. The combination of bone morphogenetic proteins with suitable carrier may fulfill these requirements. Proteins causing differentiation of mesenchymal cells in chondroblasts and osteoblasts were called Bone Morphogenetic Proteins--BMPs. The authors extracted BMP from bovine bones and placed it into collagen carrier formed from generally accessible hemostatic sponge--Spongostan. The implants were grafted into rat femoral muscle pouches in order to trace the tissue response. Pathologic examinations were performed 3, 6 and 8 weeks after implantation. On the basis on macroscopic and microscopic examinations it was stated that collagen sponge speckled with BMP caused minimal tissue response and evolved characteristic thin connective tissue capsule formation around the implant. The connective tissue penetrated spongious structure of the implant, filling the spaces, which became growing due to sponge resorption. Characteristic hyalinization and sparse chondroblasts were visible 8 weeks after implantation.