The impact of lymph node density as a predictive factor for survival and recurrence of tongue squamous cell carcinoma.

The oral tongue is considered the most frequently involved site in cases of oral squamous cell carcinoma (OSCC). Lymph node (LN) density, defined as the number of positive LNs divided by the total number of resected LNs, is considered an important prognostic factor in OSCC; however the cut-off point remains uncertain. A retrospective study was performed involving 104 patients who underwent a glossectomy procedure for oral tongue squamous cell carcinoma (OTSCC) between the years 2008 and 2018. LN density and other related prognostic factors, including pathological N-stage (pN), extranodal extension (ENE), perineural invasion (PNI), and depth of invasion (DOI), were investigated in relation to survival and recurrence rates. pN + stage, the presence of ENE, the presence of PNI, and increased DOI were found to be associated with increased LN density values, as well as lower patient survival and higher recurrence rates. The statistical analysis identified a cut-off point for LN density of 2.5%. In advanced stage disease, LN density values above 2.5% had a significant impact on the survival rate (P = 0.005), as well as the recurrence rate (P = 0.038). In conclusion, in addition to other previously known prognostic factors, LN density may serve as a strong prognostic factor for survival and recurrence in patients with advanced- and early-stage OTSCC.

Skeletal stability in patients with clefts after large maxillary advancements using intraoral distraction.

Maxillary hypoplasia is a common outcome in patients with cleft lip and palate after surgical and orthodontic interventions, and maxillary distraction osteogenesis has become a useful procedure for patients with extensive maxillary deformities. The aim of this study was to evaluate long term (two years) stability after maxillary advancement of more than 10mm by distraction osteogenesis in cleft patients using internal devices. We organised a retrospective study on 42 patients with cleft lip and palate using cephalometric analysis before and after maxillary distraction osteogenesis and evaluated them for 24 months. Postoperative measurements showed a marked advancement with an increase of 13.3mm and 10.8° in the length of the maxilla (Co-A) and SNA, respectively, including a shift from Angle class III to class I in dental relations. Follow-up observations showed preservation of maxillary length with a relapse of only 6.0 % (mean (SD) 0.8 (0.7) mm) and 10% relapse in SNA angle (mean (SD)1.1 (1.4) °) one year postoperatively and a negligible regression at the two years' follow up. This large-scale study shows stable results of skeletal advancement using distraction osteogenesis, indicating safe and reliable outcomes among patients with cleft lip and palate.

Sandwich osteotomy for the reconstruction of deficient alveolar bone.

Alveolar bone deficiency is a very common problem encountered by the practitioner when planning dental implants. The severity of the deficiency is variable. Many practitioners perform augmentation using the method they feel comfortable with and do not necessarily use the most appropriate method. This is a retrospective study on 21 patients between the ages of 25 and 63 years exhibiting moderate vertical alveolar bone deficiency and treated by the sandwich technique. Mean vertical bone gain was 7.5mm. Sixty-one dental implants were inserted showing a survival rate of 96.7% with a median of 3.1 years follow-up. Main advantages of the method include minimal relapse, single operation and preservation of the native cortical bone in the occlusal surface. We believe the surgeon should maintain the capability of using different augmentation techniques and utilize them appropriately for different severities of deficiency. We wish to establish a paradigm for using different augmentation methods We recommend using the sandwich technique in the moderate deficient cases as described in this work, using alveolar distraction osteogenesis for the severe cases as described in our previous work, where lack of soft tissue for proper closure is a major limitation, and using guided bone regeneration for minor deficiencies.

Maxillary tumour-induced osteomalacia.

Tumour-induced osteomalacia (TIO) is a rare paraneoplastic form of renal phosphate wasting that results in severe hypophosphatemia, defective vitamin D metabolism, and osteomalacia. In the case reported here, maxillary TIO was not diagnosed for 6years, although initial complaints were reported when the patient was 12years old. Meanwhile she suffered from profound growth limitation, pain, weakness, and spontaneous multiple bone fractures, culminating in complete loss of ambulatory ability and severe limitation in daily activities. At age 18years, she finally received an accurate diagnosis and definitive treatment was administered. She underwent a partial maxillectomy with complete removal of the tumour, resulting in a full cure. Shortly afterwards the patient regained the ability to walk, no longer needing the wheelchair to which she had been confined. This definitive diagnosis was based on three modalities: (1) fibroblast growth factor 23 analysis (high levels of the secreted hormone were found on the left side of the maxilla in the facial vein and pterygoid plexus, pinpointing the tumour location), (2) octreotide scan, and (3) 68Ga-DOTA-NOC-PET/CT. TIO removal via partial maxillectomy led to a complete reversal of this patient's health condition, restoring her ability to walk and function. The importance of prompt employment of these diagnostic modalities and the high level of clinical suspicion required in such cases are clear.

Two-stage reconstruction of the severely deficient alveolar ridge: bone graft followed by alveolar distraction osteogenesis.

Distraction osteogenesis for the augmentation of severe alveolar bone deficiency has gained popularity during the past two decades. In cases where the vertical bone height is not sufficient to create a stable transport segment, performing alveolar distraction osteogenesis (ADO) is not possible. In these severe cases, a two-stage treatment protocol is suggested: onlay bone grafting followed by ADO. An iliac crest onlay bone graft followed by ADO was performed in 13 patients: seven in the mandible and six in the maxilla. Following ADO, endosseous implants and prosthetic restorations were placed. In all cases, the onlay bone graft resulted in inadequate height for implant placement, but allowed ADO to be performed. ADO was performed to a mean total vertical augmentation of 13.7mm. Fifty-two endosseous implants were placed. During a mean follow-up of 4.85 years, two implants failed, both during the first 6 months; the survival rate was 96.15%. In severe cases lacking the required bone for ADO, using an onlay bone graft as a first stage treatment increases the bone height thus allowing ADO to be performed. This article describes a safe and stable two-stage treatment modality for severely atrophic cases, resulting in sufficient bone for implant placement and correction of the inter-maxillary vertical relationship.

Sporadic versus syndromic keratocysts-Can we predict treatment outcome? A review of 102 cysts.

OBJECTIVES: Keratocystic odontogenic tumor (KCOT) demonstrates variable growth mechanisms and biologic behavior, partly due to origin and histology. We looked for the most contributing factors in predicting outcome of treatment. SUBJECTS AND METHODS: We retrospectively reviewed 118 medical files of patients diagnosed with KCOT (by tissue biopsy before surgical treatment) with/without nevoid basal cell carcinoma syndrome (NBCCS) from 1995 to 2015. Data were recorded and analyzed statistically to determine the treatment-outcome correlation. KCOTs in NBCCS patients were termed "syndromic" and random KCOTs termed "sporadic." RESULTS: Of 102 cysts, 32 were diagnosed with NBCCS. Sporadic KCOTs were significantly larger upon diagnosis (p < .017). Factors most indicative of postsurgical complications are older age (p < .011), upper jaw location, and size of lesion ≥9.5 cm². Sporadic KCOTs significantly increased the chances of complications approximately threefold (p < .043). Higher recurrence rate was significant in syndromic cysts (47%) compared to sporadic cysts (20%) (p < .009). Recurrence time was 3 years on average. CONCLUSIONS: Postsurgical complications may be expected in: older patients, upper jaw location, extensive lesions, and sporadic KCOT. Most KCOT recurrence is diagnosed 3 years from treatment.

[Impacted wisdom teeth: To extract or not to extract? Review of the literature].

Impacted wisdom teeth are the last teeth to erupt and many times the first to be extracted. Unlike the teeth erupting earlier in life, eruption of wisdom teeth is often accompanied by pain, difficulty in mastication, dysphagia and acute pericoronitis which require systemic medication and surgical removal. Wisdom teeth extraction is a relativelycommon procedure in oral surgery. However, the surgical procedure itself is not devoid of complications, particularly those of deep- impacted, full-bony teeth or severely-angulated teeth. There for, there are many cases in which the practitioner prefers to avoid the surgical procedure and instead recommends follow-up routine only. It is a well known fact that the longer impacted wisdom teeth remain in the jaws, the higher the risk for related pathologies such as dental caries, Periodontal disease, cysts and tumors. In addition, as the patient ages, the risk of local and systemic complications increases, during or after the extraction. Our aim was to review the literature regarding the effects of asymptomatic impacted wisdom teeth during the course of human life.

[Distraction osteogenesis of deficient alveolar bone prior to dental rehabilitation].

Implant supported rehabilitation has become very common in treatment plans nowadays, yet many patients lack the vertical and horizontal bone dimensions required for endosseous implant insertion. Distraction osteogenesis is a technique in which bone is generated by progressive elongation of two bone fragments following an osteotomy or corticotomy. Distraction osteogenesis of the alveolar ridge as a treatment modality in implant dentistry is a very useful technique that allows for adequate bone formation suitable for implant insertion. Alveolar distraction can be unidirectional, bidirectional, multidirectional or horizontal. Alveolar distraction osteogenesis can be performed by using intraosseous distraction devices, intraosseous distraction implants or by extraosseous devices which are the most prevalent today. Distraction osteogenesis has many advantages such as gradual lengthening of the bone with no need for an autogenous bone graft and lack of the associated donor site morbidity as well as distraction of the surrounding soft tissue together with the transported bone. One of the major challenges when using alveolar distraction osteogenesis is controlling the vector of distraction, this problem should be further addressed in future researches. We describe different methods for alveolar distraction osteogenesis, including the surgical procedure, latency period, lengthening and consolidation period. We also discuss the advantages, disadvantages and complications of the method. In this manuscript a case of mandibular alveolar deficiency following mandibular fracture and loss of teeth and the alveolar bone is presented. This patient was treated by alveolar distraction osteogenesis with excellent results. This patient was later rehabilitated . using endosseous implants as demonstrated by radiographs. Alveolar distraction osteogenesis provides a method to regain both hard tissue and soft tissue without additional grafting and is an efficient modality in cases of medium to severe bone loss.

Internal mandibular distraction to relieve airway obstruction in children with severe micrognathia.

Congenital craniofacial malformations such as Pierre Robin sequence or Treacher Collins syndrome are associated with mandibular micrognathia, resulting in obstructive sleep apnea (OSA) due to a decreased pharyngeal airway; in severe cases this leads to tracheostomy dependence. We present a series of 18 patients in whom we performed mandibular lengthening using internal distraction devices to relieve airway obstruction. Seven were tracheostomy-dependent and 11 were respiratory distressed without tracheostomy. The mandible was distracted at a rate of 1mm per day. Following 3 months of consolidation for bony maturation, the distraction devices were removed. Results demonstrated forward mandibular elongation of a mean 22mm (range 20-25mm) and an increase in SNB angle and in pharyngeal airway. All patients with tracheostomies were decannulated, and there was an improved airway with resolution of signs and symptoms of OSA and elimination of oxygen requirement in all patients. We conclude that mandibular distraction using internal devices is a useful and comfortable method for younger children to expand the mandible forward and increase the pharyngeal airway.

The reverse quad helix expander: easy access for bone graft manipulation in the cleft maxilla.

Cleft-affected patients are characterized by a normal/almost normal posterior maxillary width and a severe anterior constriction of the maxilla in the mixed dentition period. The purposes of this paper were to present: two cases of unilateral cleft-affected patients treated with a reverse quad-helix appliance; and a new method for differential expansion of the premaxillary area of the palatal cleft using a reverse quad-helix expander, thus enabling improved access for the surgeons during secondary bone graft procedures. /// Orthodontic and Craniofacial Department, School of Graduate Dentistry, Rambam Health Care Campus and Bruce Rappaport Faculty of Medicine­Technion, Israel Institute of Technology, Haifa, Israel. aizenbud@ortho.co.il

3D vector control during alveolar ridge augmentation using distraction osteogenesis and temporary anchorage devices: a new technique.

This report describes a combined orthodontic surgical technique involving vertical alveolar distraction using temporary anchorage devices (TADs) in cases of massive alveolar ridge bone and teeth loss. A combined surgical orthodontic protocol included presurgical orthodontic preparation and a preimplantation surgical augmentation stage for insertion of a vertical distractor. During the active vertical alveolar distraction process TADs were inserted. Intraoral orthodontic elastics were attached to the main orthodontic archwire exerting multidirectional forces to control the vertical distraction vector. After 3 months of vector controlling and active bone moulding, the TADs were removed. Anterior alveolar ridge augmentation using distraction osteogenesis was achieved. The application of TADs for better anterior segment curvature enabled dental implant insertion, better positioning and restoration. A combined surgical orthodontic management protocol involving vertical alveolar distraction osteogenesis for augmentation purposes is an efficient treatment method to improve alveolar ridge volume for the preimplantation stage.

[Reconstruction of the alveolar ridge by osteodistraction for implant placement].

Alveolar Distraction is a method for reconstructing a deficient or atrophic alveolar bone. Alveolar ridge reconstruction may be indicated for the atrophic alveolar process resulting from maxillofacial trauma, periodontal disease, or post aggressive large cyst or tumor resection. The aim of this paper is to demonstrate the method of reconstruction of the alveolar ridge by Distraction Osteogenesis. A total of 32 patients were treated. An alveolar segmental osteotomy was carried out and the distraction device was mounted. In patients with an extensive alveolar defect two distraction devices were placed in order to better control the vector of elongation in both bone edges. The distraction was started on the fourth post-operative day at a rate of 0.5 mm/day as necessary and according to the length of the distraction device, followed by a consolidation period of 90 days. Subsequently, the devices were removed, and dental implants were placed for osteointegration. The amount of elevation was 8-15mm. All the patients had panoramic x ray before the distraction, during the lengthening, at the end of distraction and after removal of the device. Early mineralization in the distracted area was seen radiographically during the consolidation period that increased after device removal. As a result of alveolar distraction, a segment of mature bone was transported vertically in order to lengthen the crest for better implant anchorage, either for esthetic purposes or for functional prosthetic requirements. A total of 68 implants were introduced. In follow-up at 24 months, failure of only one implant was noted, due to inadequate transported bone stability. In conclusion, distraction osteogenesis is an alternative treatment in moderate to severe alveolar deficiencies for an ideal three-dimensional reconstruction with no need for bone harvesting. This method offers the possibility to place dental implants in a correct position to obtain proper prosthetic results.

Long-term results in maxillary deficiency using intraoral devices.

Cleft lip and palate patients often present maxillary retrusion and class III malocclusion after cleft repair. Maxillary distraction is a technique that can provide simultaneous skeletal advancement and expansion of soft tissue. Twelve patients with cleft maxillary deficiency due to cleft lip and palate were treated by Le Fort I osteotomy and two intraoral distraction devices that were activated after 4 days of latency period, 1mm per day on both sides. Long-term clinical and cephalometric evaluation of one and two years demonstrate stable results concerning the skeletal, dental and soft tissue relations. In this paper we discuss the advantages of distraction osteogenesis as a method for treatment of maxillary deficiency in cleft patients in terms of stability and relapse. The indications for maxillary distraction: (1) Moderate and severe retrusion that needs large advancement as in cleft lip and palate patients. (2) Forward and downward lengthening of the maxilla with no need for intermediate bone graft. (3) Growing patients. In conclusion, maxillary distraction in moderate or severe retrusion, as in cleft patients offers marked maxillary advancement with long-term stability.

Bilateral mandibular distraction for patients with compromised airway analyzed by three-dimensional CT.

The purpose of this study was to present the method of mandibular distraction osteogenesis in order to improve airway to respiratory distressed patients due to significant mandibular deficiency, and to present the quantitative volumetric evaluation of mandible and upper airway using three-dimensional-CT (3D-CT) before and after distraction. This study involved 12 patients aged 12 months to seven years with various complaints of Obstructive Sleep Apnea (OSA) such as noisy breathing during sleep, waking episodes, pauses in respiration and daytime somnolence. Some of them were considered tracheostomy candidates. All the patients underwent bilateral mandibular distraction under general anesthesia. 3D-CT of face and neck was performed before and after distraction and a quantitative volumetric evaluation of mandibular volume and airway volume was performed. The results reveal successful mandibular advancement with increase of mandibular volume by an average of 28.24% and increase of upper airway volume with a mean of 71.92%. Moreover, there were improved apnea index and oxygen saturation and elimination of OSA symptoms. In conclusion, the results demonstrate that following distraction osteogenesis of hypoplastic mandible the volume of the mandible and upper airway increases, eliminating symptoms of OSA and preventing tracheostomy.

Bone defect repair in rat tibia by TGF-beta1 and IGF-1 released from hydrogel scaffold.

Bone repair is one of the major challenges facing reconstructive surgery. Bone regeneration is needed for the repair of large defects and fractures. The ability of TGF-beta1 and IGF-1 incorporated into hydrogel scaffold to induce bone regeneration was evaluated in a rat tibia segmental defect model. External fixation was performed prior to the induction of the segmental bone defect in order to stabilize the defect site. Hydrogel scaffold containing either TGF-beta, IGF-1, TGF-beta + IGF-1, hydrogel containing saline or saline, were inserted in the defect. Calcified material was observed in the defects treated with TGF-beta 2 weeks following the start of treatment. Bone defects treated with TGF-beta, IGF-1 or TGF-beta + IGF-1 revealed significant bone formation after 4 and 6 weeks when compared to the control specimens. X-ray images showed that solid bone was present at the defect site after 6 weeks of treatment with TGF-beta or TGF-beta + IGF-1. A less pronounced bone induction was observed in the control specimens and bones treated with IGF-1. Percent closure ratio of bone defects after 6 weeks were 40, 80, 89, and 97% for saline, hydrogel, IGF-1, TGF-beta and IGF-1 + TGF-beta groups, respectively. It is concluded that hydrogel scaffold can serve as a good osteoconductive matrix for growth factors, and that it provides a site for bone regeneration and enhances bone defect healing and could be used as alternative graft material.

[Pre-septal orbital cellulitis from odentogenic origin--combined surgical and endodontic approach: a case report].

Orbital abscesses are common infectious diseases. The etiology of orbital abscesses may vary from common sinusitis in most of the cases, to cocaine sniffing. As a result of the proximity to the brain, orbital abscesses may complicate to life threatening situations. The infectious process spreads to the orbit in several ways: hematogenous, via anatomic spaces in the maxillofacial region, direct invasion. The treatment philosophy combines surgical and Antibiotic therapy to resolve the acute phase of the disease, followed by elimination of the source. The purpose of this paper is to report a case of pre septal orbital cellulitis, that was treated surgically combined with endodontic therapy. To describe the different subtypes of orbital abscesses, differential diagnosis, imaging and treatment options.

Use of the 'shark-fin' osteotome in separation of the pterygomaxillary junction in Le Fort I osteotomy: a clinical and computerized tomography study.

Le Fort I osteotomy fails in many cases to completely separate the pterygomaxillary junction and often results in fractures of the pterygoid bone and the tuberosity, which subsequently can cause complications. The objectives of this study were to describe the specifically developed Laster 'shark-fin' osteotome and to compare its use to other methods of pterygomaxillary dysjunction. Pterygomaxillary dysjunction was performed in 10 adult patients requiring Le Fort I osteotomy. In one randomly chosen side of the maxilla, the Obwegeser osteotome was used, while the Laster 'shark-fin' osteotome was used on the opposite side. A postoperative computerized tomography of the separation at the pterygomaxillary junctions revealed that in all sites treated with the Laster 'shark-fin' osteotome, a complete or almost complete separation was obtained, whereas the use of the Obwegeser osteotome resulted in five sites with fractures of the maxillary tuberosity and three with high-level fractures of the pterygoid plates (P<0.001). Comparing these findings with the literature, we concluded that the Laster 'shark-fin' osteotome is preferable for separating the pterygomaxillary junction in Le Fort I osteotomy.

Osseous reconstruction using a membrane barrier following marginal mandibulectomy: an animal pilot study.

BACKGROUND: Invasive and malignant tumors of the oral soft tissues adjacent to the mandible are often treated with partial resection of the osseous structure adjacent to the lesion (marginal mandibulectomy). Autogenous bone graft and composite bone grafts are being used to fill the osseous defects with various degrees of success. The aim of the present study was to explore the utilization of membrane barriers and the principle of guided bone regeneration to negotiate these defects. METHODS: Following the removal of P1, P2, and P3, experimental bilateral marginal mandibulectomy defects were created in 4 adult dogs. The bone segments (measuring 25 mm x 15 mm) were then removed. Each side was then randomly selected for either experimental (titanium-reinforced expanded polytetrafluoroethylene membrane, [ePTFE-TR]) or control (repositioning flaps) treatment. Postoperatively, the animals were put on soft diet, antibiotics, and analgesics. Sutures were removed under light sedation after 4 weeks, and the area was left to heal and mature for 4 to 6 months (mean 5.3 months). The animals were then sacrificed, and block sections of the mandible were obtained for macroscopic and histological evaluation. RESULTS: The size of the residual defect (the vertical distance between the most apical depression in the ridge and the horizontal line connecting the free gingival margins of the proximal teeth) in the experimental sites (6.10 +/- 1.00 mm) was much smaller compared to the controls (10.65 +/- 0.82 mm), which was statistically significant (P = 0.0127). Histomorphometric measurements of new bone formation (NBF) revealed a similar pattern: for the experimental sites, NBF was 8.08 +/- 0.85 mm compared to 4.99 +/- 0.61 mm in the controls. These differences were also statistically significant (P = 0.0257). CONCLUSIONS: A regenerative approach to large mandibular osseous defects has been described. If this new treatment modality is further substantiated in other independent studies, it might prove a useful tool in restoring the lost osseous structure associated with marginal mandibulectomy procedures.

Expression of vascular antigens by bone cells during bone regeneration in a membranous bone distraction system.

An in vivo system of membranous bone formation during distraction has been investigated in order to follow cells that express vascular markers with the objective of understanding the neovascularization process. Concomitantly, sustained proliferation of preskeletal cells was achieved through the application of mechanical force. New capillaries and leading edges that arose by angiogenesis from the periosteal and mucosal surfaces and invaded the central zone of the regenerating distraction tissue temporally preceded the growth of delicate woven bone trabeculae from both edges of the cut bone. Concentrically arranged 'onion-like' configurations were abundant in paracentral zones and in association with mesenchymal condensations, suggesting their de novo formation in situ. Vascular specific markers, the angiopoietin receptor Tie-2 and factor VIII-related antigen (FVIIIrAg), were localized immunohistochemically in order to follow cells of vascular origin. Endothelial cells of the new capillaries, centrally located cells of the concentric configurations, pericytes, and most of the adjacent polygonal mesenchymal cells stained positively with specific antibodies to both antigens. Moreover, preosteoblasts and osteoblasts that lie adjacent to or already embedded in the osteiod of the newly formed trabeculae were also FVIIIrAg and Tie-2 immunopositive. As the source of the bone-forming cells in regenerating tissue during distraction is not yet fully understood, this observation might support the possibility of their vascular origin.