A Novel Cephalometric Approach Aiming to Quantify a Normal Range of Bony Chin Protrusion.

Introduction: Cephalometric analysis is an essential tool in the diagnostics and planning of orthognathic surgery. No objective criterion exists to facilitate decision making regarding genioplasties. Differing opinions amongst clinicians therefore leads to wide variability amongst treatment options offered to potentially suitable patients. This study has three aims. The first was to quantify the distribution of chin morphology amongst the average population using cephalometric analysis. Secondly, we sought to determine whether cephalometric parameters could be used to predict overlying soft tissue changes. Lastly, we consider the use of a new cephalometric angle, BNPg, for pre- and post-operative assessment of genioplasty patients. Methods: This study retrospectively analysed 231 lateral cephalograms. The angle between the landmarks: B point, Nasion and Pogonion was measured to generate 'BNPg' a novel unit to quantify bony chin protrusion. Results: The mean BNPg from all 231 samples was 1.12 degrees with a standard deviation of ± 1.35. Comparison between sexes showed no significant differences between male and females (P = 0.108). Furthermore, bony chin protrusion was found to strongly positively correlate with soft tissue chin appearance (r = 0.731), however, BNPg was found not to correlate with skeletal malocclusion (ANB, r = 0.085). Conclusion: The novel unit BNPg may serve as a useful tool in contributing to the determination of treatment thresholds in osseous genioplasty for desirable aesthetic outcomes and may be used post-operatively to assess outcomes also. As this is a pilot study, further clinical studies would be required to validate this parameter in genioplasty patients, both pre- and post-operatively. Supplementary Information: The online version contains supplementary material available at 10.1007/s12663-022-01784-5.

Epidermal choristoma: a case series and review of the literature.

Epidermal choristoma is a rare, congenital lesion in which islands of ectopic skin are found within the oral cavity. They present as pigmented macules or papules on the tongue. Histologic appearances are characteristic and benign. We present three cases review the current literature and recommend observation of the lesion rather than complete excision should be considered as a reasonable management option.

Popescu Technique Revisited: Review of the Literature and Case Series.

Management of vascular malformations depends on the size, type, age of the patient, location, dissemination, and depth of penetration. Treatment options include propranolol, which reduces endothelial vessel proliferation, minimally invasive sclerotherapy to induce fibrosis, or surgery. In 1985, Valerian Popescu described a new approach to treatment consisting of intratumoral ligation by compartmentalization. This technique allows for high doses of the sclerosant agent to be delivered as systemic dissemination is restricted by a series of strangulating suture loops that divide the mass into segments. We describe the management and outcome of 2 patients who presented with vascular malformations in the orofacial region and were managed using a Popescu suturing technique. Vascular obliteration was achieved by a series of strangulating suture loops placed percutaneously throughout each lesion using a curved needle with a resorbable material (Vicryl; Ethicon, Somerville, NJ). The aim was to segment the vascular malformation into manageable sections for subsequent injection of a sclerosant. The compartmentalization also ensured that the sclerosant stayed within these compartments and was not washed out into the general circulation. Good esthetic outcomes were achieved in very visible areas such as the commissure and the vermillion border. In these areas, a surgical resection would have certainly caused a disruption of the esthetics of the lips and, in the second case, probably an alteration of function. Intratumoral ligation can be used safely to achieve control of vascular malformations with good esthetic outcomes.

Mandibular swelling as the initial presentation for renal cell carcinoma: A case report.

INTRODUCTION: Renal cell carcinoma (RCC) is the most common malignant tumour of the kidney. It usually presents in an occult manner, rarely with the classical triad of haematuria, abdominal mass and abdominal pain. Up to a third of patients have metastasis on presentation and only a few case reports have involved the mandible. PRESENTATION OF CASE: We present the case of a renal cell carcinoma that presented, in a 56-year-old lady, with mandibular swelling as its main clinical manifestation. This patient presented with a 3-month history of right sided facial swelling, associated with pain and intermittent paraesthesia to the right side of the tongue and lower lip. Imaging of the mandible revealed a lesion that had caused complete destruction of the right condyle, coronoid and ramus. Ultrasound guided biopsy revealed the nature of the mass to be metastatic renal cell carcinoma. Subsequent computed tomography (CT) imaging of the abdomen and pelvis confirmed the presence of a tumour in the right kidney. Due to the advanced nature of the disease, radical treatment was not suitable, and the patient passed away 11 months after diagnosis with palliative care. DISCUSSION AND CONCLUSION: Whilst mandibular swelling is usually benign, it should be kept in mind that orofacial symptoms can be the initial presentation of systemic disease. Persistent swellings with infection ruled out, or those causing cranial nerve palsy, should be investigated further.

Oral superficial haemosiderotic lymphovascular malformation: a rare presentation.

We present an extremely rare case of a 53-year-old woman with an intraoral superficial haemosiderotic lymphovascular malformation (SHLM), also known as hobnail haemangioma. SHLM is a rare, benign, vascular tumour first described as targetoid haemosiderotic haemangioma, with only a handful of cases reported to present in the oral cavity. The diagnosis was established following complete surgical excision of the lesion, and after 14 months, there are still no signs of recurrence. Although SHLM is an uncommon condition, accurate and timely diagnosis is valuable in distinguishing these lesions from their more serious competing differential diagnoses.

A case report of unusual anatomical variation: externalisation of inferior alveolar nerve.

INTRODUCTION: The risks of third molar surgery have been well documented with damage to the inferior alveolar nerve (IAN) being one of the largest concerns. PRESENTATION OF CASE: This case report presents an impacted third molar with associated dentigerous cyst in which the IAN is externalised and runs along the lateral surface of the mandible. DISCUSSION: This is an extremely rare anatomical variation with most IANs lying inferior and lingually to third molars. This case reiterates the limitations of standard radiographic techniques such as the orthopantomogram (OPG). CONSLUSION: We would advocate the use of cone beam computed tomography (CBCT) in cases which have adverse plain radiographic features to allow appropriate surgical planning.

A missed scalp laceration causing avoidable sequelae.

INTRODUCTION: We present the case of an overlooked scalp laceration in an 81-year-old lady who presented with polytrauma following a fall down stairs. Complications that developed required more extensive treatment compared to what would have sufficed with early identification. PRESENTATION OF CASE: Imaging on admission to hospital showed multiple vertebrae and rib fractures as well as a large cranial subcutaneous haematoma with no intracerebral bleed. Before the laceration was identified, the patient developed acute anaemia requiring transfusion. Continued reduction in haemoglobin levels called for a more thorough examination of the scalp. Investigation, following copious irrigation, revealed a large laceration. The presence of infection and necrotic tissue necessitated a general anaesthetic for debridement and closure. DISSCUSSION: Diagnostic errors are more common in patients presenting with multiple or severe injuries. Initial management in trauma cases should focus on more evident or life threatening injuries However, it is important that reflections and recommendations are continually made to reduce diagnostic errors, which are higher in polytraumatised patients. Various factors including haemodynamic instability and patient positioning added to the elusive nature of this wound. Adequate examination of lacerations requires thorough cleaning as coagulated blood and other material may obscure findings. This is particularly important in scalp lacerations where the overlying hair can form a barrier that is effective at hiding the wound edges. CONCLUSION: This case highlights the importance of a thorough secondary survey; an effective examination technique would have avoided the need for extensive treatment to manage the sequelae of the missed scalp laceration.

Not so silent sinus syndrome: A case report.

INTRODUCTION: Silent sinus syndrome (SSS) is a rare disorder with protean manifestations. An absence of familiarity with ambiguous and atypical presentations may complicate diagnosis and delay management. CASE PRESENTATION: A 28year old female patient presented with a chronic history of headache, post-nasal discharge and recurrent facial pain refractory to analgesics. Enophthalmos and hypoglobus progressed over a period of 2 months, and a diagnosis of SSS was confirmed via imaging. Definitive treatment was withheld given the patient's postpartum state and improvement of symptoms. DISCUSSION: SSS typically manifests with painless and progressive, unilateral, enophthalmos and hypoglobus. Since presentation is dominated by ophthalmologic complaints, the ordinary route by which SSS is diagnosed is through ophthalmology review. The predominant complaint in our patient was chronic headaches with facial pain, and mild enophthalmos and hypoglobus were only noted 2 months later at follow-up. This represents an atypical presentation of SSS, and exemplifies the subtle and often ambiguous presenting features of this disorder. CONCLUSION: The protean manifestations of SSS mean that patients may initially present to specialities other than ophthalmology. To ensure rapid diagnosis and appropriate management, it is important that clinicians, particularly in ophthalmology, maxillofacial surgery, and ears, nose and throat (ENT), are familiar with this obscure condition.

Fatal thalamic abscess secondary to dental infection.

We present the case of poor neurological recovery and subsequent death secondary to a thalamic abscess in a 53-year-old man. This patient initially presented with sudden dysarthria and left hemiparesis while driving. Neuroimaging showed a multilobular abscess involving the right thalamus with oedema extending to the basal ganglionic region and brainstem. The source of the abscess was initially unknown and it required draining multiple times while the different causes were being explored. The patient's neurological state along with intubation made for a difficult and inconclusive oral examination. It was only after neuroimaging included tooth-bearing areas that it became evident that this patient had extensive periodontal disease with multiple areas of periapical radiolucencies. The patient underwent complete dental clearance alongside repeated drainage of the abscess. Despite initial postoperative improvement, the patient never recovered from the neurological damage and died 3 weeks later.

Benign pleomorphic adenoma of minor salivary gland showing perineural invasion: a rare entity.

Perineural invasion is a rare and sporadically reported histological finding in relation to benign lesions. We present a case of a benign pleomorphic adenoma of a minor salivary gland of the cheek, exhibiting perineural involvement. There have been no previously reported cases of minor salivary gland pleomorphic adenomas exhibiting this phenomenon. This is also the first report of this rare feature in surgical literature pertaining to the head and neck region.

Karapandzic flap for reconstruction of lip defects.

PURPOSE: Systematic evaluation of the Karapandzic flap in the reconstruction of lip defects after ablative surgery. PATIENTS AND METHODS: Patients who had a Karapandzic flap to reconstruct lip defects were analyzed with reference to demographic details, histology and location of the tumor, and dimensions of resection. The functional aspects of the reconstruction were assessed in terms of the size of the oral stoma, preservation of oral competence, and facial expression, in addition to speech, diet and ease of cutlery, and denture usage. The esthetic outcome was assessed with a 4-point scale and in addition the symmetry of the commissure at rest and function, preservation of the philtrum, and lip projection also were assessed. The complications were noted. RESULTS: Seven patients underwent Karapandzic flap reconstruction (4 males, 3 females) with an age range of 43 to 98 years. Three tumors were located in the upper lip, 4 in the lower lip, and there were 5 squamous and 2 basal cell carcinomas. The lip defects ranged from 40% to 75% of the lip circumference. The oral stoma was of a reduced circumference in all cases but did not lead to any functional compromise in terms of oral competence, facial expression, speech, diet, denture and cutlery usage, and sensation. There were no wound complications in our series. The esthetic outcome was considered excellent/good in 85% of cases. The commissure was symmetrical in all except 1 patient, the philtrum was preserved in all cases of lower lip reconstruction, and the projection of the lip was reduced in edentulous patients. CONCLUSIONS: The Karapandzic flap is a reliable technique that offers consistently good functional and esthetic outcomes after reconstruction of lip defects.