Surgical Treatment of Facial Artery Pseudoaneurysm Following Blunt Trauma: Report of a Case.

There are few reports of pseudoaneurysm of the facial artery in the literature and very little attention has been paid to their surgical management. Practitioners should be aware of this unusual complication of facial trauma and of the alternatives for treatment of pseudoaneurysms. Surgical resection of selective head and neck pseudoaneurysms provides a safe and effective method for the treatment of these vascular lesions.

Mandibular ramus/coronoid process grafts in maxillofacial reconstructive surgery.

PURPOSE: To evaluate the utility of autogenous extended mandibular ramus and coronoid process bone grafts for maxillofacial reconstructive surgery. PATIENTS AND METHODS: Twelve patients aged 23 to 76 years (mean, 52) who underwent extended ramus/coronoid process grafts for reconstruction of maxillofacial deformities due to trauma, alveolar atrophy, or iatrogenic nasal deformity. All patients had either unilateral or bilateral combined coronoid process-mandibular ramus bone grafts for their reconstruction. There was 1 nasal reconstruction, 2 unilateral mandibles, 1 bilateral mandible, 4 unilateral maxillas, 1 unilateral maxilla and mandible combined, and 1 bilateral maxilla and mandible combined. RESULTS: The procedure was considered a success when the patient's deformities were reconstructed ad integrum and when there were no failures of the dental implants placed in the augmented areas as of the longest follow-up. All patients were successfully reconstructed. There was 1 infection at a donor site that resolved with local care and oral antibiotics. All but 1 of the maxillary and mandibular alveolar augmentations underwent endosteal implant placement approximately 4 to 6 months following grafting. The nasal reconstruction restored normal function and symmetry. CONCLUSION: Using both the coronoid process of the mandible and the mandibular ramus as a source for autogenous bone graft can provide sufficient bone in quantity and quality for selected maxillofacial reconstructions.

Intranasal desmopressin versus blood transfusion in cirrhotic patients with coagulopathy undergoing dental extraction: a randomized controlled trial.

PURPOSE: Cirrhotic patients waiting for liver transplantation who need dental extractions are given fresh frozen plasma and/or platelets to correct coagulopathy. This is costly and may be associated with transfusion reactions and fluid overload. We evaluated the efficacy of intranasal desmopressin as an alternative to transfusion to correct the coagulopathy of cirrhotic patients undergoing dental extraction. PATIENTS AND METHODS: Cirrhotic patients with platelet counts of 30,000 to 50,000/microL and/or international normalized ratio (INR) 2.0 to 3.0 were enrolled in a prospective, controlled, randomized clinical trial. Blood transfusion (fresh frozen plasma 10 mL/kg and/or 1 unit of single donor platelets, respectively) or intranasal desmopressin (300 microg) were given before dental extraction. A standard oral and maxillofacial surgical treatment protocol was performed by the same surgeon. Patients were followed for postextraction bleeding and side-effects over the next 24 to 48 hours. RESULTS: No significant differences were noted between the 2 groups in gender, age, INR, platelet count, creatinine, total bilirubin, ALT, albumin, MELD score, or number of teeth removed (median 3 vs 4). The number of teeth removed ranged between 1 and 31 in the desmopressin group and 1 and 22 in the transfusion group. No patients in desmopressin group required rescue blood transfusion after extraction. One patient in the transfusion group had bleeding after the procedure and required an additional transfusion. Another patient experienced an allergic reaction at the end of transfusion, which was effectively treated with diphenhydramine. Treatment associated average costs were lower for desmopressin ($700/patient) compared with transfusion ($1,173/patient). CONCLUSIONS: Intranasal desmopressin was as effective as blood transfusion in achieving hemostasis in cirrhotic patients with moderate coagulopathy undergoing dental extraction. Intranasal desmopressin was much more convenient, less expensive, and well tolerated.

Management of condylar fractures.

Management of condylar fractures remains a source of ongoing controversy. While it appears that many condylar fractures can be managed nonsurgically, recognition of cases that require surgical intervention and selection of an appropriate procedure are paramount to success in treating these injuries. There are a variety of special considerations that are peculiar to the condylar region. This article discusses anatomic considerations, classification of condylar fractures, indications for surgery, treatment options, and complications. The goals of treatment include restoration of function and esthetics. Careful consideration and attention to the principles of fracture management, and the role of the condyle as an articulating unit and growth center, must be taken into account for the successful management of these injuries.

Bisphosphonate-induced osteonecrosis of the jaws, bone markers, and a hypothesized candidate gene.

PURPOSE: To determine whether any abnormality in serum bone markers is related to bisphosphonate-induced osteonecrosis of the jaw. MATERIALS AND METHODS: We obtained serum bone markers and other relevant endocrine assays on 7 patients with osteonecrosis of the jaws (ONJ). The assays were C-telopeptide, N-telopeptide, bone specific alkaline phosphatase, osteocalcin, intact parathyroid hormone, T3, T4, TSH, and vitamin D 25 hydroxy. Diagnostic criteria for ONJ were those formulated by the American Association of Oral and Maxillofacial Surgeons. RESULTS: Five of our patients were women. Two had metastatic breast cancer and had been treated with zoledronic acid; 1 had also received pamidronate. Three others had osteoporosis and had been treated with daily alendronate. One man had metastatic prostate cancer treated with zoledronic acid. Another man had Gaucher's disease treated with zoledronic acid. All patients had been withdrawn from bisphosphonate for at least 6 months. None was taking or had taken corticosteroids. None of the lesions had shown any significant healing and all were still causing the patients considerable distress, yet the bone markers were within the normal range as measured in our laboratory, except for intact parathyroid hormone, which was slightly elevated in 1 case of metastatic breast cancer (177 pg/mL). CONCLUSIONS: We hypothesize that matrix metalloproteinase 2 (MMP2) is a candidate gene for bisphosphonate-induced ONJ for 3 reasons: 1) MMP2 is associated with bone abnormalities which could be related to ONJ. 2) Bisphosphonates are associated with atrial fibrillation, and MMP2 is the only gene known to be associated with both bone abnormalities and atrial fibrillation. 3) A network of disorders and disease genes linked by known disorder-gene associations indicates that cardiovascular disease and bone disease are closely related, suggesting that a single drug such as bisphosphonate, acting on a single gene, MMP2, could have both bone and cardiovascular side effects different from the osteoclast inhibition that is characteristic of bisphosphonate.

Normal serum bone markers in bisphosphonate-induced osteonecrosis of the jaws.

We obtained serum bone markers and other relevant endocrine assays on 5 patients with osteonecrosis of the jaw (ONJ). The assays were C-telopeptide, N-telopeptide, bone-specific alkaline phosphatase, osteocalcin, intact parathyroid hormone, T3, T4, TSH, and Vitamin D 25 hydroxy. Diagnostic criteria for ONJ were those formulated by the American Association of Oral and Maxillofacial Surgeons. Four of our patients were women. Two had metastatic breast cancer and had been treated with zoledronic acid; one had also received pamidronate. Two others had osteoporosis and had been treated with daily alendronate. One man had metastatic prostate cancer treated with zoledronic acid. All patients had been withdrawn from bisphosphonate for at least 6 months. None were taking or had taken corticosteroids. None of the lesions had shown any significant healing and all were still causing the patients considerable distress. Yet the bone markers were within the normal range as measured in our laboratory, except for intact parathyroid hormone, which was slightly elevated in one case of metastatic breast cancer (177 pg/mL). Because the jaws have a greater blood supply than other bones, and a high bone turnover rate, bisphosphonates are highly concentrated in the jaws. This anatomic concentration of bisphosphonates might cause bisphosphonate-osteonecrosis to be manifested exclusively in the jaws and is consistent with our finding of normal serum bone markers in ONJ patients.

Osteonecrosis of the jaw associated with bisphosphonate use: Presentation of seven cases and literature review.

PROBLEM ADDRESSED: Bisphosphonates, pyrophosphate analogs, are strong osteoclast inhibitors that are used for osteoporosis and in the treatment of solid tumors with bony metastasis. There are growing reports of osteonecrosis associated with the nitrogen containing bisphosphonates, Pamindronate and Zolendronic acid therapy. Theses cases have been most commonly seen and treated by oral surgeons. An untreated maxillary osteonecrosis can lead to pansinusitis, involving the otolaryngologist in these patients' care. To the authors' knowledge, this is the first case series reported in the otolaryngology literature. PATIENTS AND METHODS: A retrospective chart review was conducted on patients presenting to the Mount Sinai Hospital Center and at Elmhurst General Hospital between October 2003 and November 2004 with a history of refractory osteomyelitis of the jaws and chronic bisphosphonate therapy. RESULTS: Seven patients were identified with both of these conditions. These patients presented with nonhealing ulcers of the mandible or maxilla. Four of the patients were on bisphosphonate therapy, and the other three had been treated with bisphosphonates. Three of the patients required extensive operations to remove the involved bone. One patient required endoscopic sinus surgery. CONCLUSIONS: Increasing reports of bisphosphonate associated osteomyelitis and the difficulty in treating these patients requires further investigation to identify the subset of patients who are at increased risk for this process. The optimal and safe duration of treatment with bisphosphonates needs to be determined.

Long-term culture of human gingival keratinocyte progenitor cells by down-regulation of 14-3-3 sigma.

Human gingival keratinocytes in culture stop proliferating after a limited number of passages. This limitation is associated with a gradual depletion of the stem cell compartment of the cell population. Human skin keratinocytes have a three- to five-fold higher proliferation capacity under similar culture conditions, and previous studies indicated that stable down-regulation of the 14-3-3 sigma protein in these cultures prevents stem cell differentiation and generates immortal cell lines without the effects of tumorigenic transformation, e.g., genotypic alterations. In this report, we demonstrate the creation of an immortalized human gingival keratinocyte stem cell line by stable down-regulation of the 14-3-3 sigma protein. Keratinocyte cultures were generated from human subjects ranging from 17 to 92 years of age and retrovirally transduced with a 14-3-3 sigma antisense RNA expression construct. In contrast to the control cultures, which propagated for only 2-5 passages and 25-35 cell doublings, the 14-3-3 sigma-transduced cultures propagated for 11 passages and 110 cell doublings so far. The percentage of stem cells measured by clonal analysis, which gradually decreased in the control cultures, increased to a steady level of over 90% in the 14-3-3 sigma down-regulated culture. This gingival keratinocyte stem cell line and others, which can be generated using the same procedure, have the potential to be useful for studies on stem cell differentiation, for developing gene therapy procedures that target the gingival epithelium, as well as a stable platform for testing oral hygiene products and as potential material for preprosthetic surgery.

The correlation between mandible fractures and loss of consciousness.

PURPOSE: The purpose of the study was to evaluate the relationship between mandible fractures and loss of consciousness (LOC) in patients sustaining maxillofacial trauma in a level I trauma center. PATIENTS AND METHODS: The study was a retrospective chart review performed at Lincoln Medical and Mental Health Center, a level I trauma center. A total of 225 hospital charts of patients who sustained mandible fractures during the period from 1997 to 2001 were reviewed. The site of fracture, number of fractures per mandible, degree of displacement, and mechanism of injury were recorded. Percentages of each category were compared among patients with positive and negative LOC. Patients with any concomitant craniofacial fractures or injuries were excluded from the study. RESULTS: The incidence of LOC in patients sustaining mandible fractures was 17.6%. Young men were most likely to sustain mandibular fractures. The male-to-female ratio was 5.6:1. More than 70% of mandible fractures were due to interpersonal violence. Among various causes of interpersonal violence, use of a fist was most common. Overall, the number of fractures per patient, the incidence of singular versus multiple mandibular fractures, and the degree of displacement were less in the group with positive LOC. Body and angle regions were subjected to higher numbers of fractures, with slight variation among the 2 groups. The most common locations for mandibular fractures were the body (26% in negative LOC group; 42% in positive LOC group) and the angle (31% in negative LOC group; 26% in positive LOC group). CONCLUSION: Nearly 1 in 5 mandible fractures was associated with positive LOC. The patient group with a positive LOC, on average, sustained fewer fractures. It is possible that when the mandible sustained fewer fractures, the dissipation of energy was reduced and more force was transmitted to the cranial vault, thereby resulting in a higher incidence of LOC.